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'OAQU 1,k,.,.CO <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <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 TANKK (UST) PROGRAM SERVICE <br /> RVICE REQUEST INSPECTION <br /> REPORT <br /> PLee I r LLfnd <br /> Facility Name: Inspection Date: <br /> Facility Addres : S i e Request#: <br /> Onsit ervice Technician's Name: ICC S rvice Technician/Installer Exp.Date: Manufa urer Training: <br /> jo &U <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <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 <br /> El ElElpositive shutdown Model: Primaps piping testing at: <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 WKf om j <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> 0 <br /> � � � � Mqj`dj�f r <br /> s <br /> [n De,- ulK0116�UIDJ &[/�AO tE Y,�&d M I k& 6,--FA i9l ua ned <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins ctor: Rece By: Title: <br /> EHD 23-04 U UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 0 <br />