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Cp49 IN•.0 <br /> SAN JOAQUIN COUNTY <br /> c' ENVIRONMENTAL HEALTH DEPARTMENT <br /> Nt• _ ;� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> j. P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.siciov.org/ehd <br /> q�,FORN� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: !RTInspe tion Date: <br /> .. 9�3n It 1-2- 1 -701 <br /> Facility Address: service Request#: <br /> 461 <br /> IOnsite service Technici n's Name: ICC Service Technicia Installer p.Date: Manufacturer Training: <br /> mmtl1 ll 5I a N�/ 7 14 <br /> f <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> Prima <br /> El El positive shutdown Model: Primary testing at: (V1��4�( <br /> si <br /> ❑fail safe Serial #: GC( <br /> ❑ NA minutes v kt <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: <br /> ❑fail 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 /> �S5 i rt 1�' G , U.c�k 4 2�, <br /> 2 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E D Inspe tor: Rec/e��v/�Id y: Title: -+ 1. t <br /> J <br /> EHI 04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />