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.F "' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ' r 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fac!i Name: Inspection Date: <br /> 19 - I l -,DO <br /> Facility d ess: Service Request Ill <br /> Ctb'15�h �fC� <br /> On ite_Semice Te hnician's Name: C Service Technician/Installer Exp. Date: ManufacturerTraining: <br /> i -� -ISb ©Para 18 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El 1 hour hydrostatic 111 Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: ❑ El hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: <br /> El line test programmed ElCaldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown ModelPrimary piping testing at: <br /> : <br /> E] p❑ fail safe Serial#: ❑ <br /> ❑ 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 /> El ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note 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 LG letter 150-1) [� Other: see below <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> oils ke '(Ox- uJOW i 04cis e AkA)s <br /> e �ri C Q Z �iA <br /> vqxt- w� ,, exec ---Vi �L Sc -Suli - <br /> v .W. o <br /> llk S lA i 1 u <br /> J O W . k D <br /> T IS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp r: Re By: Title: <br /> otAd %A4 , <br /> G 7ti <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />