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oAa��N•-1611 <br /> SAN JOAQUIN COUNTY <br /> Q. a ENVIRONMENTAL HEALTH DEPARTMENT <br /> W: <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.slgov.org/ehd <br /> koa`' <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fa y me: Inspect' n D e: <br /> ti' , 4 2kC� I1 R1L/ <br /> FIRdd,ess:AService Request#: <br /> 7 W , � , a1&( <br /> Ori ' e Servicegchnic n's Name: ICC Service Technic! nstaller Exp.Date: Manufacturer Training: eT 0 <br /> M <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> electronic Serial: El El hour hydrostatic El Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El❑ electronic Serial #: El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <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 20 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 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> INLoverfill prevention (see LG letter 150-1) Other: see below <br /> )��his UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> 1►` �' � �Yu� r <br /> Oily- Seos ,, 4J, ST) <br /> .� "O <br /> THIS FACILITY IS SUBJECT TO R INSPECTION AT 8NYJJYE AT EHD'S CURRENT HOURLY RATE. <br /> H Insect : Rec ' T' <br /> 0G <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />