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OP,G AIN••.0 <br /> _;• r-cr< ,� SAN JOAQUIN COUNTY <br /> Q. ENVIRONMENTAL HEALTH DEPARTMENT <br /> y. , 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c. •.� Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> %4\ <br /> Name: Inspection Date: <br /> �Ij 11 <br /> Facility Address: � Service Request#: <br /> 1 <br /> I/C <br /> Ons'te Serv' a Tgchgnician''�sQNam ICC Servlcce eUchnic n/lnstaller E p.Date: iMan�ufacturer Tramin . <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> F-1Elmechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: El Caldwell System El Other <br /> tw4kt❑ line test programmed <br /> eak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test ro rammed <br /> 16 sensor <br /> K positive shutdown odeWI: ' Primary piping testing at: <br /> El psi <br /> 1J fail safe Serial #: <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 /> ❑ ❑ 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 /> T IS FACILITY ll ' S BJECT TO REINSPECTION AT ANY TIOE AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins p Received By: Title: <br /> \ 46— — I <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />