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SAN JOAQUIN COUNTY <br /> ENVlf20N'MENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 'r <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.si4ov.orQlehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> fc 4 <br /> FaciliV Address: Service Request#: <br /> RJA 0 T-4-1 , Q_-�I:K, >1 C 0M5--i <br /> Onsite Service Technicia 's Name: ICC Serv� ice Tech ni n/installer Exp.Date: Manufacturer Training: <br /> MAC'd Qfln�rl K/Ov - 11q tF-INS-n <br /> SERVICE SERVICE <br /> Leak detectorSpill bucket Elminimum 5 gallon <br /> ❑ 1-1mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> E line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ D mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> Q ❑ positive shutdown Model: ElPrimarys piping testing at: <br /> El fail safe Serial#: p <br /> minutes <br /> ❑ NA <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 /> ❑ C] positive shutdown Model: <br /> ❑ fail safe Serial #: Note Please be aware that 21 containment components are required to be tested upon <br /> 1:1NA 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) 1 V Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> . V � 011 e- t 14 tom(nycit co V D&dc r- � <br /> a+ 3) b In n 10 u 10-6 <br /> Kb 12-0 M YY)1,t.L'\�k Q� 10 h <br /> '.�.� C) _<;0_t1 til4_tA C CL <br /> C c <br /> THIld FACILITY IS SUBJECT T INSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe F�veeiued By: Tit!Y)CLO t I e, 7 <br /> EHR 23-04 VST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 <br />