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'Gp0.!? <br /> _,,G SAN JOAQUIN COUNTY <br /> IOto '{ ENVIRONMENTAL HEALTH DEPARTMEN <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax.-(209)468-3433 Web:www.siclov.or, /ehd <br /> 7 RFO <br /> UNDERGROUND STORAGE TANK (VST) PROGRAM SERVICE REQUEST <br /> INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Fatcility Address: Servs equest#: <br /> I &O�s <br /> -IS1 S LAI CA ct��46 <br /> 1 <br /> Onsite Service Technician's Name: ICC Service T hnician/Installer Exp.Date: Manufacturer Training: <br /> ZI <br /> L�L,� 7 12 ®� <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 /> El line test programmed <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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> ❑ 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 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 /> e <br /> THIS F CILITY IS SU JECT TO REINSPECTI N ATffl4Y TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector: Recei By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />