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AQUf(y <br /> ?°' .rF '••G • SAN JOAQUIN COUNTY <br /> Z-► ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sogov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> vakoez' �� uo - 6 <br /> Facility Add res Sery a Request4&ww bi. L i , <br /> #: <br /> �4-1 <br /> Iq <br /> Onsite Servic' T h •cian'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:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El : El 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial: <br /> ❑ ine test ro ramme ❑ Caldwell System El Other <br /> positive shutdown �od <br /> el: .��� Primary piping testing at: <br /> El fail safe Serial#: El psi <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 /> ❑ fall 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 /> Ate r i'v�rw b�p✓1 <br /> `U -P1 l <br /> C <br /> r Y r <br /> f1 a&z f" , tri N <br /> THIS F ILITY IS SU JECT EINSPECTION AT TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: k7--l' Received By: Title: <br /> EHD 23-04 �""1 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />