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SAN JOAQUIN COUNTY <br /> e: NVIRONMENTAL HEALTH DEPARTMENT <br /> 41 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> � P.. Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sioov.org/ehd <br /> 4�fFORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspecti n Dat <br /> t�i W C&V/T Z 9 /3 <br /> Facility Address: Service Request#: <br /> �5000 GtJ, 7>r. MLK r. I vcL, ,���lL ri (3P,60(dq-5 <br /> Onsite Service Technician's Name:: ICC Service TechniclaMnstaller Exp.Date: Manufacturer Training: <br /> o!1k I �1 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Sq pill bucket minimum 5 gallon <br /> ❑ ❑ mechanical Model: — 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fall safe Serial #: minutes <br /> ❑ NA <br /> sensor Seco dory containment testing for: <br /> E] ❑ positive shutdown Model: a 6 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 /> El fail safe Serial #: Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA insist latbn,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 /> V <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received y: Title: <br /> lc)� <br /> LIZ 4 <br /> EHD 23-04 t UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />