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•?''--++��''•p SAN.IOAQUIN COUNTY <br /> + ENVIRONMENTAL HEALTH DEPARTMENT <br /> !, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sidov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility N me: Inspection Date: <br /> amp— ki'll QIPk- <br /> Facility Address: Service Re uest#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El 1 hour hydrostatic 1:1 Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <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 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 /> 1?1is USTfacility %AP)P, rA0VED to ope ate ❑ This UST facility is NOT APPROVED to operate <br /> s� r. vcowrr -�09 .4ry <br /> v i ' a. vs uyls-fa d v <br /> e vtit(2 <br /> a ' s`d SCO 0 C- W - <br /> t `t roA ",- t o%kA <br /> CU,lseal %ft PC i QAJ 6 <br /> THIS FACILITY IS SUBJECT TO REINSPECTIQ[1L,A.T.ANY, T EHD'S CURRENT HOURLY RATE. <br /> EHD InspeytaL_ Rec$ived By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />