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/Pp•�fN.•c� <br /> SAN JOAQUIN COUNTY <br /> c: ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 7. 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: Inspe to Date- <br /> Ali W01F <br /> Facility Address: Service Request#: <br /> 4?,�D-7-_7 jf ttztEc� - a&-s Q1 99DO`7 1�"�2 7 <br /> Onsite Service Technician's Name: ICC Serijdce Tec nician/Installer Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <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 /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> 1:1 electronic Serial #: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> sensor <br /> El positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> El fail safe Serial #: p <br /> 11 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 #: Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 959% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) 1 IX Other: see below <br /> ❑ This UST facility is APPROVED to operate /X This UST facility is NOT APPROVED to operate <br /> t <br /> OIC <br /> !�( / lotG <br /> o d_ <br /> THIS FACILITY SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />