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OP.4V IN. C <br /> SAN JOAQUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.siQov.org/ehd <br /> F O'RN�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Faci tty ddress: Service Request#: <br /> LA,14P TYky.6 aQe G <br /> Onsite Service Technician's Name: I C Service Technic an/Instalier Exp.Date: Manufacturer Training: <br /> Almmer �3 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> 11 line test programmed <br /> ❑ Caldwell System 11 Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ElEl❑ electronic Serial #: El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> El <br /> El fail safe Serial #: Elpsi <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 /> ❑fail safe Serial#: Note: Please be aware that 2°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) Other: see below <br /> ;,k This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> i - - Oa v1 e o� LA 0�( <br /> W 1 � ►1 <br /> Gai Y <br /> (A L, W��g <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In or: Recei y: Titna-viatllej:� <br /> V.." �. <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />