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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 9. P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> �1FORa <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 'All( L' fozrflyi. e t z,, <br /> Facility Address: Servi a Request#: <br /> ct V� oC4, )t-tc..�:� S;Q6066 _% <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket 11 minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial: ElEl1 hour hydrostatic Ll Incon TS-STS <br /> L1 line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial: ElEl1 hour hydrostatic El Incon TS-STS <br /> El line test programmed El Caldwell System ❑ Other <br /> k-7 c�ij7l sensor <br /> Primary piping testing at: <br /> '4 positive shutdown Model: �0 314 C— .2,� F-1psi <br /> ��-s f.v c..t Serial #: L 4 -;'K i <br /> 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 20 containment components are required to be tested upon <br /> 1:1 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 /> 'P This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> lky,fud <br /> ,-� ,n 8144 ed <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />