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Aqu f <br /> �o. .c G SAN JOAQUIN COUNTY <br /> iy ENVIRONMENTAL HEALTH DEPARTMENT <br /> l.; 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 5 1 S - <br /> Facility Address: Service Request#: <br /> OAL4, tt1n� 1 S S S�iP <br /> Onsite Service Technician's Name: ICC Service Techniciarill nstaI p.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket minimum 5 gallon <br /> El mechanical Model: <br /> F-1 1 <br /> ❑ line testro rammed hour hydrostatic �❑ Incan TS-STS <br /> 11 electronic Serial #: Caldwell System ISS Other& <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: ] psi <br /> ❑ fail safe Serial #: <br /> El NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Nate: Please be aware that a containment components are required to be tasted upon <br /> 0 NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> `— -, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT 4NY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Re 19iied y: Tit <br /> Le, a Q <br /> EHD 23.04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 <br />