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,oPCL uI -N Co <br /> SAN JOAQUIN COUNTY <br /> Q' '�+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> y > '. 1868 East Hazelton Avenue , Stockton , CA 95205-6232 <br /> Telephone: (209 ) 468-3420 Fax: (209) 468 -3433 Web: www . sigov. org/ehd <br /> lizo P <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> E I"�.i kk : . a l , <br /> Facility Address : U V Service Request # : <br /> Onsite Service Technician 's Name : ICC Service Technician/installer Exp. Date : Manufacturer Training : <br /> C Of <br /> t� <br /> SERVICE SERVICE <br /> Leak detector Spill bucket Xminimum 5 gallon <br /> ❑ mechanical Model : <br /> rEl ❑ 1 hour hydrostatic ❑ Incon T&STS <br /> ❑ electronic Serial # : <br /> ❑ line test programmed Elr Caldwell System Other C CC `Z <br /> _ <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial :: El 1 hour hydrostatic ❑ Incon TS- STS <br /> ❑ line test ro rammed ❑ Caldwell System D Other <br /> sensor Primary piping testing at : <br /> ❑ positive shutdown Model : psi <br /> ElEl❑ 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 El 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 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 ) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> rj „ r , w. ` aoc ` . w r , , ren 0 r 4 c) " SL 11 <br /> br P l Cr � �..� ..»�.L L f ( `t�6 1 ' ` `�^-�. + I `� ' .,C 4 rv. ,j/� _ `. ( -xj C <br /> J . <br /> AAClioDie5c ' ' '* <br /> 4 <br /> ," rte _ ' . 1 : `D \I;v e t_ crf- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD Inspector: Received By: Title: <br /> l �'~ 6 - <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />