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o?'agtN • <br /> SAN JOAQUIN COUNTY <br /> ( K LNVIRONMENTAL HEALTH DEPARTMENT <br /> ? ' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> " Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.om/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> r-EmA5 Liq�w,)(- S S oc'tScaQ <br /> Facility Address: Service Request#: <br /> Iy dS S -1Hqal <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> mit I I roaf- 1111'Li hu lo 11 1 'bcow0 1 lob il l <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> _ Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ El mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: El Caldwell System L1 Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ —psi <br /> ❑ fall safe Serial#: <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall 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 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) d Other: see below <br /> IThis UST facility is APPROVED to operate ElThis UST facility is NOT APPROVED to operate <br /> r DD -14 t n ser-% <br /> gcos*e� N V— RAOIlp <br /> c " \ <br /> eIN :Per -VNW, M6,61lxC12S \io eA <br /> g HCl h L, l� <br /> 11P-061-1 LA-3 \ \ ii r► -k1ne W C \\t, ' <br /> tn4 It1 t,4'hin r l r kS <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Re,eived By: Title: �. <br /> El 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />