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ORQ9!N. <br /> ).•�E •.O <br /> 2,• ���_;..•.y SAN JOAQUIN COUNTY <br /> N: ONVIRONMENTAL 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<<F ORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Md rcl, tan e Ske.0 <br /> Facility Address: Se ice Request#: <br /> 1 a.0 6 MO-1.04 Lo 56-lck-iv A j C4 I ,SM) 66 No"L <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> 4`2 6-/3 oplu L-ve-i <br /> SERVICE SERVICE <br /> Leak detector _Spill bucket El 5 gallon <br /> ❑ <br /> El mechanical Model: El hour hydrostatic El Incon TS-STS <br /> El electronic Serial#: ❑ Caldwell System El Other <br /> El line test programmed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> F-1 <br /> El mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> El electronic Serial#: ❑ Caldwell System El Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> F_] ❑ positive shutdown Model: ❑ psi <br /> ❑ 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 21 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% 'R 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 /> > rOs i Oi - rdlQ r 91 <br /> THIS FACILITY IS SUBJECT TO REINSPECT,9A,ATAY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect r: Receiv y Tit-le�: <br /> SCS ce�, <br /> EHD 23-04 P77 r7l I., UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />