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W. <br /> �.�.�•-QG SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> W. ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> � '. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.orq/ehci <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> TC C I- 6- ")..to 1 l-� <br /> Facility Address: Service Request#: <br /> nye nIca C C' S' <br /> Onsite Service Technician's Name: IGC Servic echnicianllnstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El Ll1 hour hydrostatic Ll Incon TS-STS <br /> E) electronic Serial #: ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket 1:1 minimum 5 gallon <br /> ❑ ❑ mechanical Model: 0 ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: ❑ Caldwell System ll Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> positive shutdown Madel: ❑ psi <br /> fail safe Serial #: 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 /> ❑ ❑ positive shutdown Model: V VLonon W S <br /> ❑ fail safe Serial #: Note: Please be aware that 21 containment components are required to be tested upon <br /> ❑ NA rrstallaticn,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 /> O Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate L This UST facility is NOT APPROVED to operate <br /> -r si ' Q, b or C SN S <br /> Al MIA w'QkK, <br /> J <br /> I �� <br /> CL4 V i k + ) C�7< Te �, 1 C'[ IG E th•' Ir <br /> ❑� 2 v ti In l-t:i ` i UJ LACI' �' S� <br /> 11 <br /> THIS ACILITY IS SUBJECT Tb REIN PECTION AT ANY TIMIE AT EHD'S CURRENT HOURLY RAT . <br /> EHD Ino Received By: r Title: _ <br /> TI/ A CL <br /> EHQ 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 <br />