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PqutN ' <br /> ).•'�-st'•.o <br /> .C; SAN JOAQUIN COUNTY <br /> to 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 /> 9��FORa <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date <br /> F,TT) t ' / �1 <br /> Facility Address: Service Request#: <br /> oppite vice Technician's Name: I Service TechniiciaanA staller Exp.Date: Manufacturer Tramin <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanicai Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> 171 El❑ electronic Serial #: ❑ 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> ElCaldwellSystem ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ _ psi <br /> El fail safe Serial #: minutes <br /> ❑ NA _ <br /> sensor Secon ary co tainment testmg ffy' • �` d <br /> [Ipositive shutdown Model: a r UDC(s) �7A.5Ae Piping �v <br /> El ❑ fail safe Serial #: a- I 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 #: Note: Please be aware that 20 containment components are required to be tested upon <br /> El 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 /> V Q *te. 1 Ta � � = <br /> Qn oX 5 C, <br /> V v 1 Yra log P.51 IV <br /> i <br /> V DY v 2, s► pA <br /> U- � p _�� t� ti sr r.,� -Fatt� :2 5t Bwbbtcs D1�e►- m � <br /> THIS FACILITY IS SUBJECT TO REINSPECTI N AT ANY TIME AT EH&StVRgENT HOURLY RATE. I <br /> EHD I ectur R ei By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />