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o.Pa`'IN c <br /> z;• �,�_. _ ,� SAN JOAQUIN 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.sigov.org/ehd, <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection D e: <br /> dX Al i z a-A/7�'_Z l( r / <br /> Facility Addre s: Service Request#: <br /> i4CC t 0�z <br /> Onsite Service Technician's Name: I is echnicia Exp.Date: Manufacturer Training: <br /> ?1,9 IL2 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: E] El hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: El Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: El111 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> Elps❑ i <br /> ❑ fail safe Serial#: <br /> 11 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#: <br /> 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 /> XThis UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> wonl <br /> d --:54zZ - A// / <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> [EHD Inspe _ R eived By: , I Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />