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OP•'4UIN• C <br /> �. �•E .oG SAN JOAQUIN COUNTY <br /> =NVIRONMENTAL HEALTH DEPARTMEN <br /> 186b East Hazelton Avenue, Stockton, CA 95205-6232 <br /> - Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> L,OI/1; /D 3 / 2- <br /> Facility <br /> Facility Address: r Service Request#: <br /> S3 a62W wt l)Y) S)0 �5 <br /> Onsite Service Technician's NarrLof ICC Service Technician/installer Exp.Date: Manuf Tte,Training:Fe •,kacr �1 3 � � i z 124,q It2 <br /> SERVICE SERVICE <br /> Leak detector 002 VSpill bucket E/minimum 5 gallon <br /> ❑ ❑ mechanical Model: (g G-1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed 1tc <br /> Leak detector .r I+' pilI bucket CYminimum 5 gallon <br /> El ❑ mechanical Model: E] hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed El electronic Serial#: ❑ Caldwell System ❑ Other <br /> ' sensor <br /> ❑ positive shutdown Model: �� �Jb � � ❑ Primary s iping testing at: <br /> ❑ fail safe Serial#: gq�Zi j: p <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 /> ❑ ❑ 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) ❑ Other: see below <br /> M This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> - ald /� cT4f/� ✓� <br /> alAp 11THIS FACILITY IS SUBJECT TO REINSPECTI AT NY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: { Receive y: Title: <br /> EHD 23-04 / UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />