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'oPqu I ,N <br /> _.• E '�i SAN JOAQUIN COUNTY <br /> Qr + ENVIRONMENTAL HEALTH DEPARTMENT <br /> N*06 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 <br /> Telephone: 209 46& 3420 Fax: 209 468-3433 Web: www . sigov . org/ehd <br /> Ali FORS` <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> 11 , <br /> Facility Address : ^ ,� Service Request #: <br /> Ma Irl ieca , /� -' {` j re 0 O is5� 563 <br /> Onsite Service Technician 's Name : ICC Service Technician/Installer Exp, Date : Manufacturer Training : <br /> L <br /> "( 1, <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model : 7 Spill bucket Elminimum 5 gallon <br /> ❑ 1:1 electronic Serial # : <br /> ❑ 1 hour hydrostatic El Incon T& STS <br /> . <br /> ❑ line test programmed ❑ Caldwell System NOther Ccs r� s '�y' l PHte t vh <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 /> sensor Primary piping testing at : <br /> 1:1 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 R �T S 0 �;U CLCoaVL <br /> ❑ Overfill prevention (see LG letter 150- 1 ) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> { vne SS T)See =Lnklic � C <br /> v <br /> a -E' X� I l S i- s c JOVIn <br /> This caci U ` I\s �" V v-fd to cecc &p Tupf ) h fhr, fxj,�] <br /> THIS FACILITYIS SUBJECT TO REI S ECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD Inspector: Received By : Title : <br /> CIG�jY <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />