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oPa,u I,N,,.c <br /> SAN JOAQUIN COUNTY <br /> Q. x ENVIRONMENTAL HEALTH DEPARTMENT <br /> y $ > ?. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> iP Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s*gov.org/ehd <br /> 9L%FpR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit ame: Inspection Date: <br /> .Q, -Tr ux)--11 Q�tl u -, <br /> Facility A ress: Service Request#: <br /> Cv-- C 0 (-cis C)X q-0 <br /> Onsite Service Technician's Name: ICC rvi_-T-_hniclaMnstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector AuC—� Spill bucket minimum 5 gallon <br /> ❑ mechanical Model: K7 <br /> El El electronic Serial 1 hour hydrostatic El Incon TS-STS <br /> #: <br /> ❑ line test programmed <br /> El Caldwell System Other d,( h <br /> Leak detector �e <br /> u Spill bucket ) minimum 5 gallon <br /> F-1 11 <br /> mechanical Model: 1 hour hydrostatic Incon TS-STS <br /> 11 electronic Serial #: � El <br /> Caldwell System �ryOther <br /> El line test programmed 7� <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 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 /> Q97-7 Q, <br /> c <br /> N I - <br /> Vill CD <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp c or: ReceivBy: Title: <br /> �.n� c 4,f, I /---, , <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />