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Pquip <br /> 30SAN JOAQUIN COUNTY <br /> m ^•rr < ENVIRONMENTAL HEALTH.DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> a P. Telephone: (209)468-3420 Fax: (209) 468-3433 Web:www.sigov.oralehd <br /> 4Ci.,oR�v <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name. Inspection Date <br /> Facility Address: Service Request#:• <br /> Onsite Service Technician's�Name: ICC SeD a Techniciapllnstaller Exp.Date: Manufacturer Training: <br /> �t,y1rr 3I/7 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: ❑ ❑ I 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 /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for.' <br /> ElElpositive shutdown Model: UDC(s) Piping <br /> fail safe Serial Sump(s) UST(s) <br /> ❑ NA <br /> sensor ® Testing fpr the�above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#. Note: Please be aware that 2°contomment components areregmred to be tested upon <br /> ❑ NA installation,6 months after,and every 3 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 /> �4 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> ") iN/'-; Pa'A /",7,d...le'Jl/ ll r '); •�% ('... <br /> its/r �. 'Ss . �fr�� L-/ 'f � v�r'`• � .J.r`7f �rf rf'i�i. <br /> J`h"."-' (, <br /> / �f <br /> lJ�/l�fJ / '�fLC�`I �`a <br /> TH19 FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector ` /,� Wf Received 8y:�,., Tltlei <br /> EHD 23-04 �,, ,/f[ '''Y� UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 <br />