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SAN JOAQUIN COUNTY <br /> ; .—ori_., .G <br /> er 2 :?A ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue , Stockton , CA 95205-6232 <br /> 44 0400 Telephone: (209) 468- 3420 Fax: (209 ) 468 -3433 Web: www . sigov . org/ehd <br /> ORam <br /> �`P <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> C 20 <br /> Facility Address : Service Request # : <br /> I l /\j 4/ 114a P lL l r c� 6+ of � � S ,_ GiJ ;elOU <br /> Onsite Service Technician 's Name : l0b service T c nician/Installer Exp. Date : Manufacturer Training : <br /> AJLt /I O8 12 Zo Z (aA%L / 3 i lot? c' ' f <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 <br /> El mechanical Model : Spill bucket ❑ minimum 5 gallon <br /> F1 ❑ electronic Serial : ElEl1 hour hydrostatic 11Incon TS - STS <br /> ❑ line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at : <br /> El Elpositive shutdown Model : Elpsi <br /> ❑ fail safe Serial # : minutes <br /> ❑ NA <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 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 ) Rr Other : see below <br /> ❑ This UST facility is APPROVED to operate 4d This UST facility is NOT APPROVED to operate <br /> lJh <i ' W nk e slkoyf c LD Srh <br /> e ,941h a 4 r 4 id 4 <br /> s w 44 ,Tech, <br /> i its f� }` rece44oiei oto f 4a n <br /> Q( Q c. c2 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> D Inspector: % Receivedy: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />