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OA0.UtNC I 1 <br /> ?•'�'t '•O� SAN JOAQUIN COUNTY R, � 2,3 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> . 2 •.P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.segov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspectio Date: <br /> c 0070 031�S 2a j <br /> Facility Address: Service Request#: <br /> 900 E- K ,If If rrX a vx L., Lo c�i SD�D08+40 S <br /> site Service Technician's Name: ICC Service Techniciangnstaller Exp.[late: Manufacturer Training: <br /> iGC- UiT in�Faq��„ gll�A* W <br /> Zp <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 /> ❑ 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 /> F-1 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 /> Uf This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> r: V1. <br /> 'zraij,dxr-eVI StC�cQ q H C <br /> 2-7 - � k. l ��►1 tvlh Q � \ <br /> ti <br /> k-S S�t4c 6S <br /> ee Glt Cr, cc, (':�1661A . <br /> THIS FACILITY IS 5 BJECT T REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I tor: Received By: Title: _ c� <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />