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OP0.0 IN'•.0 <br /> SAN JOAQUIN COUNTY <br /> Q: s -NVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> A<<FORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 40-) 01 q-// 2 <br /> Facility Address: Service Request#: <br /> 3 'z 11 NS; sfioG ^ S20-0,G,- 3 <br /> Onsite Service Technician's N e: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> 1 Ps Al a-Y✓(s 0,Y1 611 "/13 <br /> SERVICE SERVICE <br /> Leak detector <br /> 1-1 mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> D electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> F-1 F-1positive shutdown Model: ElPrimarppiping testing at: <br /> si <br /> ❑ fail safe Serial #: <br /> minutes <br /> L1 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 21 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 /> ❑ 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 /> fD <br /> to <br /> A <br /> 44 <br /> THIS FACILITY IS SUBJECT TO REINSPECTI AT NY T AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: LReVid y: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />