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Aquty. SAN JOAQUIN COUNTY <br /> �°•;,�.r:•boa <br /> e `2a ENVIRONMENTAL HEALTH DEPARTMEN <br /> �IIL1�_ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sogov.org/ehd <br /> qtl FORS` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilie: Inspection Date: <br /> VW <br /> Facility Address: I Service Request#: <br /> �11�0�3 <br /> f <br /> Onsite Service Technician's Name: I Service Technici n/Installer Exk.Date: Manufacturer I raining: <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 <br /> El El shutdown Model: ElPrimarps iping 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 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 /> b <br /> ar <br /> k h l <br /> 11HIFACILITY IS SUBJECT TO REINSPECT ON AT ANY TIME AT EHD'S UR ENT HOURLY RATE. <br /> EHD=Inspo Re Title: <br /> EHD 23-04 y� Pnre [E J� �p]y� r&/ Ap" s R CE RE INSPECTION REPORT <br /> Rev 4/30/12 ' l �jC( �l '` �T CJ 1 �-'Cbq C <br />