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oAq�IN• c <br /> ? ' o SAN JOAQUIN COUNTY <br /> - { <br /> ONVIRONMENTAL HEALTH DEPARTMENT. <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> cq�ikiiRc'�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 6+Ir�;'l0— & 101t%1i-z-- <br /> Facility Address: Servicd Request#: <br /> Onsite Service Technician's Name:f ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> CIC-4, <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El electronic Serial: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed El Caldwell System El Other <br /> sensor <br /> El positive shutdown Model: ElPrimarps 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 <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> CS y-Tez :-ehv-- <br /> Cwt <br /> THIS FA ILITY IS SUBJECT TO REINSPECTI..0 AT AN IME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins Recei Title: <br /> EHD 23-0 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/1 <br />