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PqufN <br /> �o.• "" •.o SAN JOAQUIN COUNTY <br /> ar a ENVIRONMENTAL HEALTH DEPARTMENT <br /> y i_ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sugov.org/ehd <br /> �/FpRt, <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Faci'ty Name: Inspection Date: <br /> k-Lof i 61$ !9 -�)G <br /> Facility Address: Service Request#: <br /> �-Icl- -Poa-e- RA 2DERW 6 8121R 12) <br /> Onsite Service Technician's Name: ICC Service TechnirW,'an/Ins Iler Exp.Date: Manuf(act�urr�kr Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El ❑ mechanical Model: El El 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <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 <br /> El positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial#: p <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: J G LU L-+> CLU-- <br /> ❑ fail safe Serial#: <br /> Note: Please be aware that 2'containmUt 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 /> Cl 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 /> bkA10 1 Srnf i Iti �U1�c.r_ �g <br /> r CIt <br /> VvAoti rn i v� - v <br /> J �o tS bdLed <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHb'S CURRENT HOURLY RATE. <br /> EH I pector: R ceived By: Title: <br /> Q rtu� O a <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />