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ow8 rN • <br /> �'"�* '• SAN JOAQUIN COUNTY <br /> e SFA <br /> t ENVIRONMENTAL HEALTH DEPARTMENT <br /> w <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www.sFgov.org/ehd <br /> FO <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> `Sc of c , — —I <br /> Facility Addres : Service Request#: <br /> wa�ncO A S -7uo S <br /> Onsite Service Technician's Name---J C Service Techniclanfliftstaller Exp. Date: Manufacturer Training: <br /> El <br /> cep r 1D-a - ► o - -5- <br /> SERVICE SERVICE <br /> Leak detector Spill bucket minimum 5 gallon <br /> Ll mechanical Model: <br /> ❑ taldwell System ❑ Other hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> E] ❑ positive shutdown Model: El —psi <br /> ❑ fall safe Serial#: <br /> El NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ 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 /> ❑ fad safe Serial#: Note: Please be aware that 20 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 /> C { l tft 2 <br /> 'C - \ tfii,t mum an a.SS OA-0 <br /> THIS FACILITY IS SUBJECT TO REINSPECTIO T ANY T E AT EHD'S CURRENT HOURLY RATE. <br /> EHD pectora Received By: T <br /> ?- C <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />