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O.P•n•U1ly C <br /> ).• '.d <br /> �,• � SAN.IOAQUIN COUNTY <br /> 4' + ENVIRONMENTAL HEALTH DEPARTM tP <br /> , ki <br /> :• _ :, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ;.. - ,_•..e Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov.orgiehd <br /> 4�;i bo , <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Na �� Inspection Date: <br /> Facilityv Addres <br /> _ fin i Service Request#: 66(-L(I <br /> onsite Service Technician's Name: ICC Service Tech nicianllnstaller Exp,Date: Manufacturer Training: <br /> G1t1T '>� lC S3Z3 �,9 V k V 75) Qao IbA <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 Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: El 1 hour hydrostatic F1lncon TS-STS <br /> ❑ electronic Serial #: LJ Caldwell System 11 Other <br /> ❑ line test ro rammed <br /> sensor : <br /> ❑ <br /> LJ positive shutdown Model: Primary piping testing at L1fail safe Serial#: El psi <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 /> 171 <br /> y:❑ positive shutdown Model: <br /> ❑ fail safe Serial#: <br /> 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 /> ❑ <br /> El <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 /> L1 i- �x rdvl <br /> THIS/FACIZITY IS SUBJE T TO REINSPECTI ANY TIME A HD'S CURRENT HOURLY RATE. <br /> EHD n pect Receiv B Title: <br /> 1A1 <br /> El 2 <br /> Rev 41 0112 4 UST SERVICE REQUEST INSPECTION REPORT <br />