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Op'•4u'IN••C � 1�� <br /> SAN JOAOUIN COUNTY 1LL! <br /> (2 —cry ENVIRONMENTAL HEALTH DEPARTMENT <br /> �y 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c•• P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.slgov.org/ehd <br /> 4��FORN` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#- <br /> 0 AA <br /> q q 341 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> S )0 ,5 V 1 zZc, ul z <br /> SERVICE SERVICE <br /> x Leak detector Spill bucket El minimum 5 gallon <br /> X5Zmechanical Model: fT4 Z '� I El El hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El E-1❑ electronic Serial #: 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: psi <br /> Primary piping testing at: <br /> ❑ D 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: <br /> ❑ fail safe Serial #: 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 /> ❑ 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 /> k ' <br /> teS <br /> uAA SV <br /> Q <br /> 11 <br /> THISYAgfLITY IS PYBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Ip WC!or ,-/, Received By: Title: <br /> L L <br /> EH[ 23- UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30 2 <br />