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PWP <br /> O,'atJ I N • • <br /> SAN JOA,QUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> util > '{ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: 209 468-3420 Fax: 209 468-3433 Web:www.s*_ov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> MIUD hm 51is I �'. <br /> Facility Address: Service Fillequedt <br /> Onsite Service Technician's Name: ICC Service Technician/Inst r Exp.Date: Man ufactureT Training: <br /> Ly k <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: ❑ El El hour hydrostatic 11 Incon TS-STS <br /> El electronic Serial#: ❑ Caldwell System El Other <br /> El line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: ❑ Caldwell System El Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <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 21 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 LIS letter 150-1) Other: see below <br /> } ;d <br /> ElThis UST facility is APPROVED to operate ElThis UST facility is N�T AP R VED to operate <br /> 3t J9 ALA T G <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIMf AT HD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Cceiyed By' <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />