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ACLU I IV <br /> �o.• -.-" •.co SAN JOAQUIN COUNTY <br /> 'PENVIRONMENTAL HEALTH DEPARTMENT <br /> 4 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.s*gov.org/ehd <br /> so <br /> UNDERGROUND STORAGE TM (UST) PROGRAM SERVICE REQUEST INSPECTION I REPORT <br /> Facility Name: Inspection Date: <br /> 1 ® —77v` 13 <br /> Facility Address: 1 Service Request#: <br /> r <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: 8jb <br /> -IDS c6o-ST�t <br /> v <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket r_1 minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> 171 ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> positive shutdown Model: El psi piping testing at: <br /> El El❑ fail safe Serial#: p <br /> ❑ NA minutes <br /> sensorndar containment testing for: <br /> El positive shutdown Model +�ZV <br /> 1 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 /> El ❑ fail safe Serial#: <br /> Note: Please be aware that 20 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 /> LN This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> AA 0 <br /> C <br /> P <br /> ® S - <br /> i <br /> d <br /> THIS FACILITY IS SUBJECT TO REINSPE TION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD tor: Receive By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />