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a p�lU I IV <br /> 1•'�cE •.p <br /> SAN JOAQUIN COUNTY <br /> ^� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.smgov.orglehd <br /> del o <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: l Inspection Date: <br /> X17 �i 1 a[ U, — -C-3--i� <br /> Facility Address; Q Service Request#: <br /> 1`-1 D� A (- `7 a'Lj 01 <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> mechanical Model.- Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: © ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model Spill bucket Ll minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> L'll 51sensor <br /> �positive shutdown Model: Primary piping testing at: <br /> ❑ fail safe Serial#: ❑ psi <br /> El 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#: <br /> ❑ NA Nate' Please be aware that 21 containment components are required to 6e tested upon <br /> 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% Ci Corrosion protection <br /> ❑ Overfill prevention (see LO letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> s c Vin- , N 0 n ',V 1 L-))-N.'to . <br /> 0 c <br /> 1 <br /> 1I n 0 L L C ct C, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION T A Y- E AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: J Ree ed B Title <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130/12 <br />