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Opc�UI!y C <br /> SAN JOAQUIN COUNTY <br /> 2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> •:i <br /> W. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sogov.org/ehd <br /> O R� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> tjuo <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <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 <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> 11 Caldwell System ❑ Other <br /> vita,i),am4i`Lsensor <br /> ❑ positive shutdown Model'��� tik' E � Primary piping testing at: <br /> ❑fail safe Serial #: jo`-k�1<u ❑ psi <br /> 11 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 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 /> CtuvvkiAky,\ 4yc, cAj "V1 -c, 24" <br /> L �G \l.,'V VAIL )\OC ,.tA& 4\�,- Cv + Sic <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> HD Ins -Werra eceiv By: Title: l:Te' <br /> ,j _jc <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />