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0.ufN <br /> SAN JOAQUIN COUNTY <br /> �.•a,E� •.oG <br /> 2 r-r�r ENVIRONMENTAL HEALTH DEPARTMENT <br /> N: 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209) 468-3433 Web:www.s*- ov.or(j/ehd <br /> q�%FpRN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: SeAir) �rv�e equest#: <br /> ., <br /> 14 DID 1� <br /> Onsite Service chnician's Name: ICC Ser vi a Technic ian/InstaIler Exp.Date: Manufacturer Training: <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 <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 1:1 line test ro ramm ❑ Caldwell System ❑ Other <br /> RWa sensor L�k- r1'J I ,✓ <br /> El shutdown Model: Primary piping testing at: <br /> ❑ fail safe Serial #: I �� <br /> it) a 2_ El psi <br /> ❑ NA I minutes <br /> �6A-WXWsensor LSIrIA►'✓) Secondary containment testing for: <br /> ❑ positive shutdown Model: UDC s Piping <br /> in <br /> 9 <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> Zsensor ❑ Testing for the above components are next due by: <br /> ❑ positive shutdown Model: u <br /> ❑fail safe Serial #: 0c 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 UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> S V1Ul�GU` n, S cit men&e l. 1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME A EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: R y: Title: :1�z <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 0 <br />