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• --�:.�, w2 SAN JOAQUIN COUNTY <br /> 'a;• ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> + .' Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sioov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: � Inspection Date: <br /> Q C oto 11 -li —/ Cv <br /> Facility Address: Service Request#: <br /> 1D33 �- 7 a <br /> Onsite Service Technician's Name: I ervice Tec hnicianllnstaller xp. Date: Manufacturer Training: <br /> � 1 q - 12 -1 L1 -o,2oit11j <br /> SERVICE SERVICE <br /> Leak detector Spill bucket Elminimum 5 gallon <br /> El ❑ mechanical Model: <br /> El electronic Serial Ely <br /> ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model <br /> LJ electronic Serial# El Eloury <br /> 1 hhydrostatic 11 Incon TS-STS <br /> : <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> p <br /> El positive shutdown Model:11 fail safe Serial#: El Primary <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> El Elpositive shutdown Model: I g o / UDC(s) Piping <br /> ❑ fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor T ng for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: (fit ID, aj 1-, <br /> ❑ fail safe Serial #: Note Please be that 2- ontainment components am 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 /> S t n it / <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME T EHD'S CURRENT HOURLY RATE. <br /> EHQ Inspector: Receiv Title: /I <br /> /PCv! <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />