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OpgU 1 N••.0 • <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N.%. _ �', 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �9�%F O,FRN�P <br /> Telephone:(209)468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit ame: Inspect' n Date: <br /> 'IV 21- 6— <br /> Facilit ddre Service Request#: <br /> � U OVA` ��� M 6 � <br /> Ons'te ServicezTchhician's ame: IC rvice Technician/Installer Exp.Date: Manufactur r Training: <br /> IZVP31k li�(,p 0111 VM I -m V/9 q/0 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> mechanical Model: ElEl1 hour hydrostatic El Incon TS-STS <br /> electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> positive shutdown Model: �-U Primary piping testing at: <br /> El psi <br /> fail safe Serial #: <br /> 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 20 containment components are required to be tested upon <br /> ElNA 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 /> 1 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> L' <br /> / S o <br /> Zl� <br /> F L E <br /> THIS FACILITY IS SUBJECT TO REINSPECTIO AT"YMME AT EHP'S CURRENT HOURLY RATE. <br /> EHD I s e Receive j y Ti <br /> EHD 23-04 / UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />