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? � •p� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> N. 18t,� cast Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209) 468-3433 Web:www.s*gov.org/ehd <br /> ��rFOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> C fir? a j / 0 ho <br /> Facility Address: Service Request#: <br /> I- AM/7ZZrA , <br /> Onsite Service Tech i . n's Name: ICC Service Technicia nstaller 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 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 /> F] El positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> El NA minutes <br /> sensor Secondar containment testing for: <br /> F-1Elpositive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor X Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: �'��/,� ,��� Ic)" <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 /> d St s <br /> s ec <br /> O r -� C-7 <br /> S C' <br /> HIS FACILP IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT i1iOURLY RATE. <br /> EHD Inspector: Rece may: Title: <br /> AL <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />