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oQQUJ <br /> 7 c <br /> �E�'•o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> I { 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> i;0R� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fac"lity Name: Inspection Date: <br /> its VeA e ( -411 Y-H anrec <br /> Facility Address: t Service Request#: <br /> po 0-C <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> t <br /> Leak detector I <br /> s s Spill bucket LYminimum 5 gallon <br /> rhanical Model: �-��� ( 1 hour hydrostatic ❑ Incon TS-STS <br /> tronic Serial#: � 1�i C�t'��-i'ine test programmed <br /> ❑ Caldwell System EYOther �_(-c, <br /> Leak detector <br /> Model: �G t..17 � Spill bucket El minimum 5 gallon <br /> � [�;mechanicai' <br /> El electronic Serial#: 0,0'N pC? (� ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> El line test programmed <br /> sensor <br /> ❑ <br /> El shutdown Model: ElPrirna Primary testing at: <br /> si <br /> ❑ fail safe Serial#-. <br /> EI 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 positive shutdown Model: <br /> © ❑ fail safe Serial#: <br /> 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 /> X/This <br /> UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> i <br /> - Don 'A Q 40 TeX T ,�►tov� ��-� 7aok 4 <br /> 1 <br /> ,1 " JrC#4& `/O V2 <br /> J r i <br /> NOULT)er V10 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYTIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector- 7R�r!i�W_By. Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130/12 <br />