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O. -N— <br /> ........... <br /> C`. <br /> 'p SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ":�: I 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c P Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> k • CLk tip oo�q 13 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Ex . Date: Manufacturer Training: <br /> CC�rn 1�, j I'b' I°� NOv- -q - )..o 1 pXcwC) ll 3 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ <br /> El electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <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 /> sensor <br /> ❑ <br /> El positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑ fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor pec nontainment testinfor: <br /> ❑ ❑ positive shutdown Model: �J UDC(s) 1 — 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 " — VVO :5�4�z)vnul <br /> ❑ fail safe Serial #: Note: Please be aware that 20 containmei 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 9500 ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 950,0 ❑ 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 /> om <br /> V ► - - a <br /> THIS FACILITY ISS JECT TO REI Y Tl 1E ATE D'S CURRENT IOURLY RATIA. <br /> EHD Inspec r: O Rec t Title: d� <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />