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U.I.... <br /> r=;• ;_...�.,_., :c� SAN JOAQUIN COUNTY <br /> A ENVIRONMENTAL HEALTH DEPARTMENT <br /> t 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ' Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> ,gC1�ORN�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility T�j <br /> Inspection Date: <br /> 14 Q / <br /> Facility Address: Service Requd9t#: <br /> p aA , � U( CA _ <br /> Onsite Service Technician's me: I Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> El electronic Serial#: El Caldwell System El Other <br /> El line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> El electronic Serial #:test programmed ❑ Caldwell System El Other <br /> sensor Primary piping testing at: <br /> positive shutdown Model <br /> fail safe .� v Serial#: ti L1 psi <br /> NA minutes <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 LIS letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> THIS FACILITY IS SUBJECT TO REINSPES. IME AT EHD'S CURRENT H URLY RATE. <br /> EHD Inspect r: Rece B L2 <br /> Inc4_ <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />