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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N4 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> FoR°'�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> �se�s Q Q-Jq-01101 <br /> Facility Address: Service Request#: <br /> �\-�� 'W'r eeQ S R- �---o �- <br /> Onsite Service Technician's Name: [cc Service Technicia Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket 11 minimum 5 gallon <br /> El El <br /> 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: - n <br /> ❑ line test programmed El Caldwell System X Otherd CSV <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El❑ electronic Serial #: El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> ❑ <br /> El 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 #: <br /> Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA Iinstallation.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 /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> �Vl bi 2rvs- r KA �C Lva Q'U <br /> S w &A llve <br /> & e '\ins QA OK-- <br /> Ill 1rzo) 4n, loyv U <br /> C ion <br /> s cvY,e eo <br /> (-I-A A d AL2 VVJ �&6 aA —�W a0nh�t�+ WDIN (2��Qk <br /> 'U <br /> THIS'FACILITY IS SUBJECT TO REI SPECTION AT ANY TIV AT EHD'S CURB NT HOURLY RATE. <br /> EHD Inspecto : Received By: VTitle: r <br /> Q "Itc ktit C Ir L Vol <br /> EHD 23-04 ( _ UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />