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O.Pqu ( !v • .0 <br /> �. �•,E•E •o� SAN JOAQUIN COUNTY <br /> 2 ��rOVA ENVIRONMENTAL HEALTH DEPARTMENT <br /> y 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 <br /> Soo <br /> Telephone: (209) 468= 3420 Fax: (209 ) 468- 3433 Web: www . sigov . orq/ehd <br /> cq �iFOR��P <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> i <br /> Facility Name : Inspection Date : <br /> Q, �o � ! bi a <br /> Facility Address : Service Fle4uest #: � � O to <br /> OO r fir • <br /> Onsite Service Technician 's Name : ICC Service Tec WarYinstaller Exp. 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 Seria # : ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at : <br /> ❑ ❑ positive shutdown odel : ❑ psi <br /> El fail safe Serial # : minutes <br /> ❑ NA <br /> Sens o Secondary containment testing for: <br /> ❑ ❑ positive shutdo, n Model : UDC ( s) Piping <br /> ❑ fail safe Serial # : Sump ( s) UST (s ) <br /> ❑ NA ❑ <br /> ensor Testing for the above components are next due by : <br /> ❑ ❑ positive hutdown Model : <br /> ❑ fall Safe Serial # : Note: Please be aware that 20 containment components are required to be tested upon <br /> ❑ NA installation, 6 months after, and every 36 months thereafter. <br /> ❑ rop tube with mechanical overfill at 95 % ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95 % ❑ Corrosion protection <br /> ❑ Ov rfill prevention ( see LG letter 150 - 1 ) Other: see below <br /> ❑ his UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> 01 e- COAX 10 4 <br /> I 1IM <br /> 9 it Pk mewy/W qop U Aa:: y <br /> v ► W c� <br /> S ' I t <br /> va* MetA e 2 t Q <br /> cv h s 1e Ww w1ke,0Aty <br /> vaAA cj/tA It &W Moz, c cs <br /> THIS FACILITY IS SUBJECT TO REIINSPECTION,AA ANY TIME AT EHD ' S CURRENT HOURLY RATE , <br /> EHD Inspec pq B : Title : <br /> a, o . 4'v1 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 l �� <br />