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o.P4uIN c <br /> >.•..�Ei'••.o <br /> SAN.IOAQUIN COUNTY ' <br /> < %w ENVIRONMENTAL HEALTH DEPARTME~ <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.orglehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> S-D 4< -Z &4) <br /> Facili ddress: I A ' Service Request#: <br /> �O V W' <br /> Onsite Service Technician's Name: ICC Service Tec icianflnstaller Exp.Date: Manu cture ning: <br /> S � <br /> SERVICE SERVICE <br /> _Leak detector _Spill bucket 13 minimum 5 gallon <br /> El ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic L1 Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ElOther <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El El1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El❑ fall safe Serial#: psi <br /> ❑ NA minutes <br /> — <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 Le aware that 2c containment components are requireci to be testetl upon <br /> ❑ NA installation,6 months after,and every%months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95%-d ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate UST• fauifity-is NOT APPROVED to operate <br /> ZO r^�4 <br /> � <br /> I AL&U01 <br /> r <br /> CA <br /> c <br /> ,c' <br /> THS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins Received By: Title <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />