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AQuI(y <br /> �o coG SAN JOAQUIN COUNTY <br /> e Za <br /> *NVIRONMENTAL HEALTH DEPARTMEN <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> •. y- �� <br /> Telephone: (209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <br /> aCi k O RP <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Oarxer o7i 41 o s P,+tALj 3 /'ZO / Z01 3 <br /> Facility Address: A Service Request#: <br /> ® m Coe t <br /> Onsit Service Technician's Na ;!x, -�+04-+o '5 r- <br /> me: ICC Service Tech cian/installer Exp.Date: Manufacturer Training: O/(� yZ 3 <br /> �d �✓ �/1 Looil ow <br /> �t <br /> SERVICE SERVICE <br /> Leak detector Spill bucket minimum 5 gallon <br /> echanical Model: fi41 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( <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: tJ/ <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 /> r <br /> VCS r5 Li i° <br /> �Y '' d' lid f tis <br /> VK1prodC � ttf v��G �� a44d 7S GGkICe/ �v� <br /> Cox.- <br /> q ,- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In ect Receive Title: <br /> A 'A2 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />