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PgU1N <br /> SAN JOAQUM COUNTY <br /> a: a cNVIRONMENTAL HEALTH DEPARTMENT <br /> y 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> C`qC;oRa�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> C r v( ,s-C►^ Ak A <br /> Facility Address: Service Request#: <br /> 1 l 3 W _ 1_t� l'�1►�b d�'�a;v�' ' s r- a 0 � �k <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> z d Zol <br /> SERVICE SERVICE <br /> Leak detector <br /> 1:1 mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: ElEl1 hour hydrostatic ElIncon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> 1 sensor S} <br /> ❑ positive shutdown Model: 5 q710-1 00 Primary <br /> Primary s iping testing at: <br /> ❑ fail safe erial#: 5 ( �_ minutes <br /> ❑ NA &►' <br /> sensor Secondary containment testing for.- <br /> E] <br /> or:❑ ❑ 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 2°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) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate Y� This UST facility is NOT APPROVED to operate <br /> Sed +Q-5 h yv-P laa.1 <br /> �,. <br /> o© c c d a <br /> A S lS tc <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY IME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I pect Received Title: <br /> Lv a►� <br /> EHD 23-c(/ UST SERVICE REQ ST INSPECTION REPORT <br /> Rev 4/30/12 <br />