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SAN JOAOUIN COUNTY <br /> (,Q? 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 /> cq� 1FORNj <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> aIev, /U r) <br /> Facility Address : Service Request # : <br /> 1 � © c t� f J \aja tL ' S0- C) 0 6 of 2- <br /> Rnsite Service Technician ' s Name : ICCS_ erv_ chnician/installer Exp . Date : Manufacturer Training : vR ._. .7 <br /> 2 Q_ <br /> I �tQx,Vv �i � Q -t VM-C - � - � <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model : d. Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial # : ❑ 1 hour hydrostatic ❑ ncon TS - STS <br /> ❑ line test programmed <br /> El System Other (1 <br /> Leak detector q I g ; <br /> El mechanical Model : T Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ 1 hour hydrostatic Incon TS - STS <br /> ❑ electronic Serial # : ❑ Caldwell System Other e <br /> ❑ line test programmed Ql YL <br /> sensor <br /> El shutdown Model : Primary piping testing at : <br /> ❑ ❑ fail safe Serial # : ❑ psi <br /> ❑ 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 20 containment components are required to be tested upon <br /> ❑ NA I 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 eTi n akVT i wc, oaeAkOyu <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> tits► eQ va. 0ST to U04A 0 VA 1jQWRLb0 f <br /> Seus� �s 5V►2CL wUQ. 0ea 'e VCLWUrn YO C04 <br /> ved� � w S i w i r► �s L e oo <br /> WOL <br /> ryxCS Ct L <br /> tii CvG 1 os h <br /> xu TA" � '+2,�, O 02L 9A0, 0AT & GL\ oqR vvm V <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIVE AT EHD ' S CURRENT HOURLY RATE . <br /> EHD Inspgctor: �R � Recei By : Title : <br /> woo,1 W t <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />