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O P''0.U I N'•.0 <br /> SAN JOAQUIN COUNTY <br /> Q. -+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> y`• .?. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> . P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.orq/ehd <br /> 4�f FORa` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> FacilitName: Inspection Date: <br /> (0 6 '$ 6q 1)'i ' 15 <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service T ician/lnstaller Fxp.Date: Manufacturer Training: <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 #: El Caldwell System El Other <br /> El line test programmed <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 2°containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> g4 O'Drop tube with mechanical overfill at 95% ❑ I Cold start of monitoring panel <br /> a 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 /> v ) Q vv", ( 1, c <br /> v <br /> o l �h Qom- Q <br /> 601MLAW t,A dine z- ^y, ---' e z 'ay <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: A MNReceived By: Title: <br /> 41�L2 le-ck <br /> EHD 23-04 1 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />