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o.Pa�IN••.c <br /> SAN JOAQUIN COUNTY <br /> Q' �+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> N: { <br /> _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax.(209) 468-3433 Web:www.s4gov.org/ehd <br /> qC/O <br /> UNDERGROUND STORAGE TANK ( 1ST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> CA <br /> Facility Address: _ ■ Ser ce Fieguest� r <br /> f /K)•a' 0 l <br /> Onsite Service TechnigGlan's Name: 1 ICC Service Technician/Instailer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> F-1 ❑ electronic Serial:: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El El 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 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 LIS letter 150-1) ❑ Other: see below <br /> El3 -f� r This UST facility is APPROVED to operate � facility s�NOT APPROVED to operate <br /> 112 <br /> �' Ne <br /> S ' N,9, Ah 104 <br /> '�'V, y <br /> " a'svy' <br /> ii r c <br /> THIS FACILITY IS SUBJECT TO REINSPECTION A ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe r. Received By: Title: !� <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />