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OPqu t N•.0 <br /> SAN JOAQUIN COUNTY <br /> 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.sogov.org/ehd <br /> ���IFORN`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: In� �ct' Da <br /> —tleT—l" � <br /> LF 'I*t Address: S vice Request#:Servic ech ici s Name: IC Service Tech nician/InstaIler Exp.Date: Manufacturer raining: <br /> SERVICE SERVICE <br /> Leak detector -� Spill bucket ❑ minimum 5 gallon <br /> IQ mechanical Mode ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: j3n �I �$� <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ElElElpositive shutdown Model: p <br /> si <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 /> ❑ ❑ positive shutdown Model: <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 /> t <br /> L� 1lJV <br /> C <br /> THIS FA ILITY IS SUBJECT TO REINSPE TION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector. Re illed Bye_.__ Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />