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�qutN <br /> ?°'�''•a� SAN.IOAQUIN COUNTY <br /> . � �-► ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.si4ov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> bexs De iA 15116 1011 <br /> Facility Address: Service R quest : <br /> Onsite Service Technician's Name: ICC Service Technician/Installer E p. at Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ElIncon TS-STS <br /> El line test ro rammed 11 Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> El El positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial#: p <br /> El NA minutes <br /> sensor S cond ry cntainment testing for: <br /> El El positive shutdown Model: ! �` 1k1DC(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 /> << -2� <br /> r-,5,k0A <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD InspectoReceived By: Title: <br /> h GK �, y ✓i`�C/ .Jet' <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />