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O.Pa U I N••.0 <br /> SAN JOAQUIN COUNTY <br /> a' A ENVIRONMENTAL HEALTH DEPARTMENT <br /> til < <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> qC/FOR��. <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request' <br /> L4z? " Nds 7W2�>.;759.2 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> it / <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial: El El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> T Spill bucket L91iminimum 5 gallon <br /> ❑ ❑ mechanical Model: 1 hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: I❑ Caldwell System El Other <br /> ❑ line test programmed <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ fail safe Serial #: ❑ 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 20 containment components are requirea 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) ElOther: see below <br /> M/This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> / <br /> TH FA ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins p toR Ived By: Title: <br /> < �� ✓iCL TGC-. <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />