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oRautN o SAN JOAQUIN COUNTY <br /> Z� — %a/ENVIRONMENTAL HEALTH DEPARTMEMIilimI( <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.s'gov.orolehd <br /> 4�tFOFa� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> S 8 I I 201 3t t" <br /> Facility Address: SeRequ <br /> 1616 41tt4l"irl <br /> Onsite Servic Technician'sNa e: ICC Service TechnicianfInstaller Exp.Date: Manufacturer Training: <br /> �(A -ZYl^ <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> E) El mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> El positive shutdown Model: ElPrimarysiping testing at: <br /> El fail safe Serial #: p <br /> ❑ NA minutes <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 2 containment components are required to be tested upon <br /> 11NA 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% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) JgOther: see below <br /> ❑ This UST facility is APPROVED to operate ❑-- This UST facility is NOT APPROVED to operate <br /> q l� �n <,P b <br /> � w <br /> IaA 14eJ <br /> 4 Jill; Y1 e 1 4V <br /> � o <br /> z <br /> THIS FAC[ IS SUBJE T TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe Received By: Title: <br /> EHD 23-04 7 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130/12 <br />