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�o• : _ <' p SAN JOAQUIN COUNTY <br /> 'Sk ENVIRONMENTAL HEALTH DEPARTMENT <br /> N;. <br /> `• I ; I 1868 East Hazelton Avenue , Stockton , CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468- 3433 Web: PPPPP/ . sigoy .org/ehd <br /> `tet<iPo <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: <br /> Inspection Date: <br /> Facility Address: Service Request It: <br /> Onsite Technician's Name: ]C0 L CSer <br /> ervice Technician/ a ler Exp. Date: Manutacturer Training: <br /> Jon all"" %-I l I Vol poii Kilo <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 # : 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 ewers that 20containmentcomponents are required to be tested upon <br /> ❑ NA Installation, o months aper, and every 36 morthe 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 /> 71Overfill prevention (see I letter 150- 1 ) Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> 13 <br /> V l 'Q ` l K aOAA <br /> VV� coo X01 e � . <br /> - I IL e. o I wh Heol <br /> � 6o i 1 voce,, � le H e.� S1�o fQmI <br /> Ia woo l( ec,t 1 1kajIliallom 43L&: t 0M <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT HD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Re d By: 00Title: <br /> LV <br /> MrWAZM <br /> W �✓ '✓vz�o s -�c <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 1 O •� <br />