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i <br /> 4/ IN , <br /> ' •,�, SAN JOAQUIN COUNTY <br /> c. -+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> N I 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 <br /> 1 Tele hone: 209 46 & 3420 Fax: 209 46 & 3433 Web : www . sigov . org/ehd <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Namei Inspec ion Da <br /> Facility Address : Service Request # : <br /> cXZ40X I � � g i. ��� LD 0 0 3 4 3 <br /> Onsite Service Technician 's Name : ICC Service Technician/Installer Exp . Date : Manufacturer Tramin : a <br /> f I 1 iG ka �u( kkv\ �aov �6 ( �1 I Q U �' W ( Sr3 ) Q� 1��PIiL <br /> SERVICE SERVICE <br /> Leak detector <br /> 1:1 mechanical Model : Spill bucket El minimum 5 gallon <br /> E-1 ❑ electronic Serial # : ❑ El hour hydrostatic ElIncon TS - STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model : Spill bucket ❑ minimum 5 gallon <br /> ❑ El electronic Serial # : ❑ ❑ 1 hour hydrostatic ❑ Incon TS - STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> sensor Primary piping testing at : <br /> ❑ ❑ positive shutdown Model : ❑ psi <br /> ❑ fail safe Serial # : minutes <br /> ❑ NA <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 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 Pitt W <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 /> DIN VL Lectevy <br /> crql <br /> c / Spill c1 C <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> Ei( Inspector: Received By : / Title : r <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />