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� SAN JOAQUIN COUNTY <br /> 46ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.siaov.or /g ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspecti n Date: <br /> t , <br /> -,/q h ti <br /> Facility Address: Service Request#: <br /> c2057S. 977 sr-ZVO-110to <br /> 1 lovd—O < <br /> Onsite Service Technician's Name: ICC Serv'ce Te nicianllnstaller Exp.Date: Manufacturer Training: <br /> I <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ' ❑ Caldwell System Other <br /> Elline test ro rammedWa <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon_ <br /> El ❑ ❑ 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#: <br /> El 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 /> ❑ 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 US facility is APPROVED tq 9perate [IThis UST facility is NOT APPROVED to operate <br /> EX c4zL S>-+ �Q2//I cm W' "r et) <br /> �Rfi=THISFACILITY IS JECT TO REINSPECT AT ANY AT EHD'S R ENT HdbRLY RATE. <br /> EHD Inspector: Received By: Title: <br /> 6 _ c <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />