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O.PQ U(N••.0 <br /> SAN JOAQUIN COUNTY <br /> r. —err ENVIRONMENTAL HEALTH DEPARTMENT <br /> c• 'a <br /> N . 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> dqC'oRa�P <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 Nam Ins tion Date: <br /> - lot.— <br /> /0 <br /> ,� <br /> Facility dress: � , �I � Se�ce Request#: <br /> . 1A6.7(�96 <br /> OnsVe Setvice Tec nici n's Name: ICC Ser ice Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> c ''t. 'Ceak detector <br /> '0 mechanical Model: �wt1 Spill bucket ❑ minimum 5 gallon <br /> El El electronic Serial #: r�/i 7 I u j� ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> 9 mechanical Model• ����'/�� Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> line test programmed ❑ Caldwell System ❑ Other <br /> —UU,^ ',+ ensor <br /> ❑ positive shutdown Model: `793�c�"�fi1r7 Primary piping testing at: <br /> ❑ psi <br /> ❑❑ failsafe �re�,a S ial #�+ 1 minutes <br /> sens r �j Secondary containment testing for: <br /> ❑ positiv4 shutdown Model: 'i °- UDC(s) Piping <br /> ❑ ❑ fail safe Serial #: Sump(s) UST(s) <br /> El NA 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 /> 0 45 <br /> QQ ✓ <br /> JeA4, r r'4� <br /> 23 <br /> W el <br /> THIS ACIL IS SUBJECT TO INSPECTION AT ANY TIME AT EHD'S CURRENT FOOURLY RATE. <br /> EHD Inspector: e�c+eived By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />