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O.t`4ur�• - <br /> >: <br /> •c �(,, SAN JOAQUIN COUNTY <br /> �/ tNVIRONMENTAL HEALTH DEPARTMENImO <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �.. a Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 4�tFONH\ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> s- 2L+-� <br /> Facility Addres: 1n r r} Service equest#: <br /> 6 V 1 <br /> Onsite Servic hnician's Name: ICC service Te hniaantinstaller Exp.Date: Manufacture raming: <br /> S <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 11 minimum 5 gallon <br /> ❑ ❑ mechanical Model: El El1 hour hydrostatic L1 Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector _Spill bucket 13 minimum 5 gallon <br /> El El mechanical Model: El L11 hour hydrostatic El Incon TS-STS <br /> El electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ElOther <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El _ si <br /> ❑ fall safe Serial#: p <br /> ❑ 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 /> E] Elpositive shutdown Model: <br /> ❑ fall safe Serial#: Note: Please be aware that 2 containment components are required to Da tested upon <br /> ❑ 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 /> w I <br /> r <br /> Rft -h Mb <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: / Title: <br /> EHD 23- UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />