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!1 y <br /> �t'• SAN JOAQUIN COUNTY <br /> �. ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax. (209) 468-3433 Web:www.sigov.om/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> -firlvro n 5161 <br /> Facility Address. Servic Request#: <br /> S N -4L 5�00��$11 <br /> Onsite Service Technician's Name: ICC Service TechniciaNlnstal r Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector _Spill bucket Ll minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic LJ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El El mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> El line test programmed 1 <br /> ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ _psi <br /> ❑ fall safe Serial #: <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: ump(s) UST(s) <br /> ❑ NA ; �� <br /> sensor Testing for t e above components are next due by: <br /> ❑ ❑ positive shutdown Model: k MC>-S� <br /> ❑ fall safe Serial #: <br /> El NA Note. Please be aware that containment components are required to be tested upon <br /> installation,6 months atter,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 /> 0 A,:, S N L�— , <br /> D.CS-CA Z <br /> I <br /> i h Cd <br /> \,kW 1516 ab , <br /> 45 s n � <br /> c <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> 'r/��— <br /> EHD 23-04UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />