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O t'qu I N_.0 <br /> SAN JOAQUIN COUNTY <br /> e' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> P. Telephone:(209) 468-3420 Fax. (209) 468-3433 Web:www.sogov.org/ehd <br /> 4GiF OR1'� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> W, 1�1�- -C G W�o� d I- f <br /> Facility Address: Service Request#: <br /> 0 A -SLn o s <br /> Onsite Service Technician's Name: ICC Service Techn cianAnstagdr Exp.Date: Manufacturer Training: <br /> rout wzf� ---� - ')-Is \1Q= %-I@L- 5 v <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> echanical Model: �—o �T�� ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial #: T� <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket 11 minimum 5 gallon <br /> ` mechanical Model: A El El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> ❑ ❑ fail safe Serial#: ❑ psi <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 /> El El <br /> positive shutdown Model: <br /> ❑ fall safe Serial #: Note: Please be aware that 2 containment components are requiretl 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 /> rDLA <br /> ` o uQ 4,e8� K.D ro <br /> EPJOL,& -tq- +k4 SR h l0 s► <br /> L Ct4-0-eA-or cZ�ted Go u x t e p� <br /> 3 Q0k Per vw-ctf CLI 10 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector, y a 1 ` � Received By: Title <br /> ` <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30112 <br />