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�Aqui - <br /> ?�--�� SAN JOAQUIN COUNTY <br /> c. ai ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.orq/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 5, ,,h z& <br /> Facility Address: Service Request#: <br /> kclraq�A Ck0IS 00+ <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Traiining: <br /> KL <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 /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> [I electronic Serial: El 1 hour hydrostatic El Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> sensor <br /> ❑ <br /> El positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> J fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment tes$Ing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Ck Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor TXesting fort/he above components are next due by: <br /> ❑ ❑ positive shutdown Model: A V �S` Q�Qk— <br /> ❑ fail safe Serial #: Note: Please be aware that 2°con ainment 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 /> ; % AQ <br /> EWD <br /> clli�' Q,6 _ S 1, 01r- <br /> V— +0 ba 01 ti I akbC "I - - o— <br /> As� A0 <br /> THIS FACItITY IS SUBJE60040 RE TI TIME AT EHD'S C ENT HOURLY R <br /> EHD Inspector: ece Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />