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,oPqu IN. , c <br /> SAN JOAQUIN COUNTY <br /> o 9 <br /> y: 1< ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0. 6:0 1868 East Hazelton Avenue , Stockton , CA 95205 - 6232 <br /> met c . , Q <br /> Telephone: (209 ) 468- 3420 Fax: (209) 468 -3433 Web; www . siaov . orq/ehd <br /> A� IPOR�; <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date : <br /> hismod f4 � <br /> Facility Address : Service Request #: <br /> /00 fi d? �2 ��jU �� o, <br /> Onsite Service Technician 's Name: ICC Service Te hnician/Installer Exp. Date: Manufacturer Training : <br /> 2b2() <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model : ❑ ❑ 1 hour hydrostatic ❑ Incon T& STS <br /> ❑ electronic Serial # : ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket L1 minimum 5 gallon <br /> El ❑ electronic Serial :: ❑ El hour hydrostatic ElIncon T& STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor Primary piping testing at : <br /> El Elpositive shutdown Model : Elpsi <br /> ❑ fail safe Serial # : minutes <br /> ❑ NA <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 /> El El positive shutdown Model : / aj laz o= <br /> ❑ fail safe Serial # : Note: Pleasde 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 LG letter 150 - 1 ) ❑ Other : see below <br /> Most <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> s � eM 9 21 U4 <br /> sS L72L Lad d90 <br /> too <br /> THIS FACILI Y IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD Insp r: RerlBy: Title • � <br /> zt <br /> EHD 04 ' U�� SERVICEEST� <br /> SREQUEST REPORT <br /> Rev 4/3/3 0/12 APT V7 <br />