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Op0. UIIV .o <br /> ). • .t •.O <br /> goa <br /> .� AN JOAQUIN COUNTY <br /> er .60A ENVIRONMENTAL HEALTH DEPARTMENT <br /> N . �l > "?, 1868 East Hazelton Avenue , Stockton , CA 95205- 6232 <br /> Telephone: (209 ) 468-3420 Fax: (209) 468 -3433 Web: www . sigov . orq/ehd <br /> Oda so \ <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> Ives? od hid F 7 <br /> Facility Address : Service Request #: <br /> tcRoo� a <br /> Onsite Service Technician 's Name : ICC Service Te hnician/Installer Exp. Date: Manufacturer Training : <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial :: ElL11 hour hydrostatic ElIncon TS- STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial :: ElEl1 hour hydrostatic ElIncon TS- STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> sensor Primary piping testing at : <br /> E] Elpositive shutdown Model : Elpsi <br /> ❑ fail safe Serial # : minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model : �J / / . 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: Pleasde 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 /> Z.f4SS� C 0 , <br /> f2 0 � C <br /> THIS FACILI Y IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD Ins p r: Re �By : TitleNINE <br /> ^) <br /> � <br /> EHD 23-04 ' /USERVICE REQUESTINSPECTION REPORT <br /> Rev 4/30/12 A- PT <br />