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'oAqu I ,N, C <br /> SAN JOAQUIN COUNTY <br /> .GZ <br /> er 04 ENVIRONMENTAL HEALTH DEPARTMENT <br /> N . ?. 1868 East Hazelton Avenue , Stockton , CA 95205-6232 <br /> Otto Telephone: (209) 468- 3420 Fax: (209) 468 - 3433 Web: www . slgov . org/ehd <br /> cq �iFOR��P <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> 0/e W*7 p X2/0 7 &7 7 � A/0 �o <br /> Facility Address : Service Request #: <br /> 00 /00 (1 4 <br /> Onsite Service Technician's e: ICC erv'ce Technici n/Inyt*#er Exp. Date: Manufacturer Training : <br /> A6 ll,?,rvuj <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 Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model : ❑ ❑ 1 hour hydrostatic ❑ Incon T& STS <br /> ❑ electronic Serial # : ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at : <br /> El positive shutdown Model : Elpsi <br /> ❑ fail safe Serial # : minutes <br /> ❑ NA _ <br /> sensor Secondary containment testing for : �r <br /> ❑ ❑ positive shutdown Model : UDC (s) ping <br /> ❑ fail safe Serial # : S Sump (s) UST(s) <br /> ❑ NA too <br /> sensor Testing f r the bove components are next due by : <br /> ❑ ❑ positive shutdown Model : ( 1920 <br /> ❑ fail safe Serial # : IV <br /> 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 Thli's UST� ality is NOT APPROVED qperate <br /> &S nfdt rodz6a& rcL el", <br /> O cf' <br /> S. Too -14 <br /> I'V <br /> f s W�sP eCE 7 <br /> Afj <br /> "FAend r��f <br /> IS FXCIM IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRE T HO Y RATE . <br /> EHD Ins a or: Recei ed BY: Tim <br /> je) <br /> EHD 23-04 / �Dt '9 //oval UST SERVICE EQUESTI! 4SPECTI0N RF" <br /> Rev 4/30/12 A , n �, <br /> v <br />