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OAQUtry.• <br /> ?'--•�"''o�` } SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> j1868 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 /> Facility Name: Inspection Date: <br /> vd 11.Z0L <br /> Facility Address: Service Request#: <br /> `�)_ �(� (� �f.LtCl �P 501 ;_f40 <br /> Onsite Service Technician's Name: ICC Service Technician/Install r Exp.Date: Manufacturer Training: <br /> t (ll ZU c �( 5 71120,-IC���el� vZ 1,0AP <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket DQ minimum 5 gallon <br /> El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> El El positive shutdown Model: ❑ Primaryps piping testing at: <br /> ❑ 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 <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 /> COV44 tit <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> �u v� Y— ;�r� /�ar�a e� <br /> EHD 23-04 UST SERVICE REQUEST INIOPECTION REPORT <br /> Rev 4/30/12 <br />