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'O gqulN !` <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N < <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigoy.org/ehd <br /> 9�tFOM1I�` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Datee::1C.'J� <br /> r�C <br /> LO <br /> Facility Address* L() <br /> Service <br /> 3 , 1 � /vR/lequest#: <br /> Onsite Service Technician's Name: ICC service Tec nicianAnstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> AW k detectorq;LmSpill bucket El minimum 5 gallon <br /> ❑ electronic <br /> nic Serial #: <br /> echModel: El1:1oury <br /> 1 hhydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El 1:11 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: y <br /> ❑ line test programmed ❑ Caldwell System El Other <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 /> ❑ ❑ 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 0 containment components are requireC to Im tested upon <br /> ❑ NA installation,6months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95%p ❑ 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 /> ILO <br /> ❑ This UST facility is APPROVED to operate TWwOGT�s NOT APPROVED to operate <br /> THIS FACILITY IS'SUBJECTT6 REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received B : _ Title: <br /> STS./Z-- <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />