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?` 'a • SAN JOAQUIN COUNTY i <br /> {I ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sogov.org/ehd <br /> '•'fit 1�:.:R��P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> (10S I ':—glj 4 <br /> ea <br /> Facility Address: Service Request#: <br /> 67P-W-72 <br /> Onsite Service Technician's Name: ICC ldwvice Technic' /Installer Exp.Date: Manufacturer Training: <br /> Vql <br /> SERVICE SERVICE <br /> Leak detectorbucket <br /> gS P�ill . <br /> E] mechanical Model: minimum 5 gallon <br /> ❑ ❑ electronic Serial: 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System MOther '>1zh <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El El hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> El El psi <br /> El 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#: Note: Please be aware that 2°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 /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> so azd4I�` i` <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspectorr:��, Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />