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SAN JOAQUIN COUNTY <br /> zNVIRONMENTAL HEALTH DEPARTMENI <br /> 1868 East Hazelton Avenue, Stockton, CA 95205'6232 <br /> C'qC F.RNP <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 /> Amo -I z C, I LIt'l )-,- <br /> Facility Address: Servicd R`egiupest#: <br /> Onsite Service Technician's Name: ICC Sezdag Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El Model: �� `�`�'�� Spill bucket El minimum 5 gallon <br /> El El electronic Serial#: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> 91 Leak detector ` I <br /> mechanical Model: �`�- `�µ�f-f Spill bucket ❑ minimum 5 gallon <br /> ❑ mec <br /> B e ecnic Serial: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ 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 2°containment components are required to be tested upon <br /> ❑ NA Iinstallation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% UP I Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> I' Overfill prevention (see LG letter 150-1)10ef <br /> ' a ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> s <br /> L � <br /> � (� ..C/T � :�� rr�.,r' �-%o✓�• I/� as i— <br /> ..-� ,_e- I <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT AN ' IME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rece e, By' Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />