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SAN JOAQUIN COUNTY <br /> W,; <br /> WNVIRONMENTAL HEALTH DEPARTME <br /> 4 <br /> DIY _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> F. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> C9GlFORa`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name- � l nsp ctio nate: / <br /> I <br /> Facilitydress: Vd � Service Begin #a _ p <br /> WW <br /> M <br /> chnician's Nam ICC Service T c ician/l staller Exp. ate: Ma a turer Training: <br /> � <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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <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 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 /> XThis UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Y r <br /> / rY lKe4 114 <br /> THIS FACILITY IS-91 1111 JECT YO REWSMECTION AT ANY TIME AT EHD'S CURRENT HOURLY ATE. <br /> E D nspor: ived By: Title: <br /> Rev 230/1 n L Q� '0 ? �� �(,, ._ c� ���f �y-��T rc E�U T I s ECTION�EPORT - <br /> Rev 4/30/12 ` v�/, �E.��f r v"�C._- �.Qj jn <br /> _'eC*eze w e X -6sueIN <11� _ko velry pmpe.r d4Q.,S0 a nvtk( Q-V_ <br />