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op4UtN <br /> ?•''��'•a� SAN JOAQUIN COUNTY V U <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> c: a <br /> N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ` 1 P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sjgov.org/ehd <br /> 9�fFoa�1� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket minimum 5 gallon <br /> ❑ ❑ electronic Serial #: 1 hour hydrostatic Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System Other if-O&((,-- <br /> Leak detector <br /> ❑ mechanical Model1 Spill bucket minimum 5 gallon <br /> El ❑ electronic Serial:: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System `Other � <br /> El line test programmed <br /> h.. <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <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 2°containment components are required to be tested upon <br /> ❑ NA Iinstallation,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 <br /> This UST facili y is PROVED to operate/ ❑ This UST facility is NOT APPROVED to operate <br /> UA V P- <br /> L yehyl1?e " <br /> hzw T +e, s u e A. �t <br /> ed <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EH 'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received Title: <br /> EHD 23-04 UST SERVICE REQUESTINSPECTIONREPORT <br /> Rev 4/30/12 W C7 Ci 1, VS 15C410A3 k T 0-W 9- W a c/� e ;1"`Z , V <br /> covcbo Aef51 w/o ` 5 J O4' S� <br />