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O Pqe 0 . 0 1N C <br /> ?• ' ' _E' Iso SAN JOAQUIN COUNTY <br /> ter, .2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q: � <br /> y b. ` . 1868 East Hazelton Avenue , Stockton , CA 95205-6232 <br /> Telephone: (209) 468 - 3420 Fax: (209) 468 -3433 Web: www . slgov . orq/ehd <br /> ROR�`P <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date: <br /> Facility Address : Service Request #: <br /> I68 164 I eAve Sew Vo to <br /> Onsite Service Technician 's Name: ICC Service Techniciantinsta ler Exp. Date : Manufacturer Training : <br /> SERVICE SERVICE <br /> _ Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model , ❑ ❑ 1 hour hydrostatic ❑ Incon TS- STS <br /> ❑ electronic Serial # : ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial :: ElEl1 hour hydrostatic ElIncon TS- STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor Primary piping testing at : <br /> ElElpositive shutdown Model : El psi <br /> El fail safe Serial # : <br /> El NA minutes <br /> sensor Secondary containment testing for : <br /> ❑ ❑ positive shutdown Model : UDC (s) Piping <br /> ❑ fail safe Serial # : Surrol 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 belowMEN 1AVQ( FS0 Lt <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Alp �! Q�I� �J b `t �o t <br /> s� '5 , 08s ✓e ci Z"s tNo.o ooiOAA ' ai... <br /> S W s O 'o r Si <br /> p <br /> /k\j2,AiIII S <br /> �m k Ind <br /> tea5 ilk t ` oma <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE , <br /> Eyp4nspector: Rece' d By: Title: / <br /> 1040 cx <br /> EHD 23-04 Coss UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />