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SAN JOAQUIN COUNTY <br /> t ENVIRONMENTAL HEALTH DEPARTMENT <br /> > {I 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �a 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 Name: Inspection Date: <br /> Wo-her oo Shed r/ I i9 PC <br /> Facility Address: Service R quest#: <br /> 43 15 E . Water (in q ` Rva S+o A 4z n GA 40 6 G 3 <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> +JLSef I /2- 18 VP 8 i7 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: <br /> El line test programmed El Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <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 /> 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 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) IR Other: see below <br /> 1 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> © s O 1, 1Le— <br /> r aC e Je 20 - o0 <br /> 4 �- ra <br /> Pass <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receiv y: <br /> `' Title: <br /> V <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />