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oP VIN••.c <br /> �.• .oG SAN JOAQUIN COUNTY <br /> Q { _NVIRONMENTAL HEALTH DEPARTMENT <br /> :. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> 9LjFO•�N <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name:,4IA Inspection te:I� <br /> Facility Address: ` ServiFf Request#: <br /> O ite SerTechnician's Name: ICC Service Technician/ staller Exp. Date: Manufacturer Trai ing: <br /> \k <br /> j —11-1s 1 -16-1s, 0 a-&- 5 S , <br /> SERVICE SERVIC <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> Ll ❑ electronic Serial: El 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed El Caldwell System El 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 shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> Ll NA <br /> sensorI cor�darSy�� itainment testin fpr <br /> El positive shutdown Model: UDC(s) g� t Piping <br /> El ❑ fail safe Serial #: <br /> Sump(s) UST(s) <br /> ❑ NAS <br /> ❑ p sensor Te)Q01 <br /> gfor t �EJv'lcZomponents are next due by: <br /> Ile❑ positive shutdown Model: --..�> <br /> ❑ fail safe Serial #: 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 LIS letter 150-1) Other: see below Z 131y,, S6 g )Y`a <br /> ❑ This UST facility is APPROVED to operate AoThis UST facility is NOT APPROVED to operate <br /> Sl I iN U l <br /> OCI <br /> L' i tee, <br /> THIS FACILITY IS UBJECT TO REINSPECTION AT ANY EAT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector Receiv Title: 77 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />