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°A0.utN 'Q SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMENT <br /> �IIL 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.s"gov.org/ehd <br /> A�1F0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> k 1 // 7 <br /> Facility A dress: Service Req est : <br /> 3q_/ ft44A4'/) SI A( 3x66 G G l g 3 <br /> Onsi Service Tec nicia 's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> 'f_Av'�A Z 3 <br /> SERVICE SERVICE <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 /> 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: ❑ si <br /> ❑ fail safe Serial#: p <br /> ❑ 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 /> ❑ fail safe Serial#: Note: Please be aware that 20 containment components are required to be tested upon <br /> ❑ NA Iinstallation,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) f� Other: see below <br /> EN This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> �- vi,U P,rr►r � f�t.�,-� � -�wv •- <br /> THIS FACILITY IS <br /> SUBJECT TO REINSPECTI T ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector:A w �1Receive Y. Title: r � <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />