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'dq... N, <br /> ?••-. SAN.IOAQUIN COUNTY <br /> i { ENVIRONMENTAL HEALTH DEPARTMENT <br /> i;. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.segov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspect7oDat <br /> S, r- ? rr <br /> Facility A ess: Service Request#: <br /> al 0 <br /> Onsite Service Technician's Name: ICC Service/Tech nician/Installer Exp.Date: Manufacturer <br /> Training: <br /> .7 Z �14o, <br /> VIY& <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 Spill bucket ❑ minimum 5 gallon <br /> El El <br /> mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: <br /> ❑ line test programmed El Caldwell System ❑ Other <br /> JYJG Sensor1 Primary piping testing at: <br /> El positive shutdown Model L1PP&yayi- .- ❑ 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(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 I 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 /> X. This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> ,may <br /> THIS FACILITY IS UBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: R ivedBy: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 — <br />