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OLVIN <br /> ? ' � ' ° SAN JOAQUIN COUNTY <br /> Q: �+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> y 1868 East Hazelton Avenue , Stockton , CA 95205 - 6232 <br /> Sao Telephone: (209) 468-3420 Fax: (209) 468 -3433 Web: www . si4ov . orq/ehd <br /> cq <i is o RP <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date : <br /> 19 <br /> Facility ` ddre s : Service Request #: <br /> i U( q9 � � ��- Ua �� Lkp o r o <br /> Onsite Service Technician 's Name: 16C Service Technician/Installer p. Date: Manu acturer Training : <br /> 0 <br /> r � b ��- <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model : Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial : El111 hour hydrostatic El Incon TS - STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model : Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial : El El hour hydrostatic ElIncon T& STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor Primary piping testing at : <br /> ElElpositive shutdown Model : ❑ 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 # : _ Sump (s) UST( s ) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by : <br /> ❑ ❑ positive shutdown Model : <br /> ❑ fall safe Serial # : Note: Please be aware that 20 containment components dare 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 LIS letter 150001 ) Other : see below 1 � <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> L A0 ot se � J e, msh m void e r <br /> L < <br /> b GJ� or <br /> l ('10 V <br /> I <br /> THIS FACILITY IS SUBJECT TO REINSPEAl • I N T ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD In tor: Rec i d Title : <br /> EHD 23-04 UST SERVICE411FC:ZT INSPECTION REPORT <br /> Rev 4/30/12 <br />