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O.p4U 1,N•,.0 <br /> SAN JOAQUIN COUNTY <br /> 2: err. •G <br /> e: 'a ENVIRONMENTAL HEALTH DEPARTMENT <br /> y. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.si4ov.org/ehd <br /> i:0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Amt—' 1 <br /> Facility Address: Service Request#: <br /> Ons'te Service Technicia S Name; ICC Service Technician/Install r Exp.Date: anufacturer Training: <br /> : .;" I . A V1 q)l-71 <br /> SERVICE SERVICE <br /> Leak detector <br /> I-] mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ElEl1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> _ Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: _ <br /> El NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) 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: <br /> ❑ fail safe Serial #: Note: Please be aware that 2'containment components are required to be tested upon <br /> ❑ NA Iinstallation,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 /> Ld rill m�� �s►1-i Ise � w ��� � .R � <br /> Wit%. <br /> THI$,,Fj1CILITY IS SUBJECT TO REINSPECTION AT Y TIMEAT EHD'S CURRENT HOURLY RATE. <br /> E H D Ins acfo V I Receive Bt i Title: <br /> EHD 23-04r; UST SERVICE REQUEST INSPECTION REPORT <br /> . <br /> Rev 4/30/12 �� <br />