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� <br /> �o. t.ca SAN JOAQUIN COUNTY <br /> a; ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> cQtrF.oQ��?' <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Na Inspection Date- <br /> &?,�grpo)ri- lo7qll g <br /> Facility Address: Service Request#: <br /> �q,ov ae rel✓& <br /> Onsite Service Technician's Name: ICC Servi a Icnician/Installer Exp. Date: Manufacturer Tra'nin : <br /> 2© Vi J 2l1 <br /> SERVICE SERVICE <br /> S Leak detector Spill bucket ❑ minimum 5 gallon <br /> mechanical Model: W) <br /> El electronic Serial #: � � ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed T 11 Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ F-1❑ electronic Serial #: El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> El E7 psi <br /> Elfail safe Serial #: mi <br /> El NA <br /> 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: P!ease 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 /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> w i+-n t c,%d u d div dj'�A ( v ak, dlkdl- <br /> THIS <br /> FA ITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins ctor: Re y: Ti _ <br /> A- I L.C� <br /> i <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />