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�oPqur±V\ , <br /> �'--++�'` '9`• SAN JOAQUIN COUNTY <br /> - <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ,+ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <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 /> Facili ame: Inspection Date: <br /> SOL LNf Q ca <br /> Facility Address: Service Request#: <br /> �i �; U�. �l� �vt �C� CO C S " <br /> Onsite Service Technician's Name: y ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> bar V V 6I�-�� <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> El El positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> El 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 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 }r�Js �II <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 /> VA C tQ I ( I �' <br /> V4 e y_ .Q E - <br /> to divs& atd q1 S <br /> w� l P't ( <br /> THtS FACILITY IS SUBJlkT TO REINSPECTION AT AN IME AT EH 'S CURRENT HOURLY RATE. <br /> EHD Inspe Received By: Title: <br /> __ k'( 6(1 ry) z IEHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />