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oAagIN• c <br /> SAN JOAQUIN COUNTY <br /> f.ai <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �■rl: 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s'gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> FaciliV <br /> e: Inspection Date: <br /> - tcb- iLON <br /> Facility Address: Service Request#: <br /> U&10 W <br /> Onsite Service Technician's Name: ICC ervice Technician/Installer Exp. Date: Manufacturer Trainin : <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> F1 ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> El electronic Serial #: El Caldwell System El Other <br /> El line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: <br /> ❑ line test programmed El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <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 /> El <br /> odel:❑ fail safe Serial#: Note Please be aware that 21 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 /> C <br /> s <br /> S <br /> OT)Uaf5 6 �� ,het V_Q.� 0 <br /> e- rn <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EH 'S CURRENT HOURLY RATE. <br /> EHD Insp or 3:v Re By: Title: s15( <br /> 0 ma'm I U )d� I <br /> 4 <br /> EHD 23-04 _ r C, UST SERVICE REQUEST INSPECTION REPORT <br /> ("l <br /> Rev 4/30/12 `� -�I 0, <br />