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SAN JOAQUIN COUNTY <br /> er ENVIRONMENTAL HEALTH DEPARTMENT <br /> L •'t <br /> y. _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.s'gov.org/ehd <br /> �<iFORr' <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: V V / Service equest#I: <br /> V W <br /> go- <br /> Onsite Service Technician's Name: ICC Service Technician/Install Exp.Date: Manufacturer Training: <br /> t2,(.3 VM[ vetl3 M((j <br /> i <br /> ERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed ❑ Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: El El hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed <br /> 11 Caldwell System El Other <br /> sensor <br /> ❑ El shutdown Model: El psi piping testing at: <br /> El 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 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 ❑ This UST facility is NOT APPROVED to operate <br /> _A4,a,YM 4M VV-01 OE E66d pV r.r l <br /> C• e <br /> t <br /> THIS FACILITY IS SUBJECT TO REINSPECT <br /> Y TWEAT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe R eive Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />