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tN, <br /> �'"�t'•. - 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.sigov.org/ehd <br /> lit SII FOPNvv <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facil' Name Inspection Date: <br /> lk II - �- IS' <br /> Facility Address: Service Request#: <br /> Onsit Service Technician's Name: ICU Service Technicia nstaller Exp. Date: Manufacturer Training: <br /> / _ -A - to - 6 - <br /> z-t - <br /> SERVICE SERVICE <br /> Leak detector <br /> LJ mechanical Model: _Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El El mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: g, <br /> ❑ <br /> 11 positive shutdown Model: psi <br /> ❑ fall safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> El ❑ 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 #: No[e 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 LIS letter 150-1) c❑ Other. see below <br /> ❑ This UST facility is APPROVED to operate M/ This UST facility is NOT APPROVED to operate <br /> St 71 <br /> 31 Ili,I gwkO <br /> S_ <br /> (� LIMN <br /> SI <br /> THIS FACILITY IS SUBJE T TO REINSPECTION AT ANY TIME ATE S CURRENT HOURLY RATE. <br /> EHD In r Rece B Title: <br /> WA <br /> c <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130/12 <br />