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�A U C <br /> SAN JOAQUIN COUNTY <br /> cr ENVIRONMENTAL HEALTH DEPARTMENT <br /> I <br /> Nt.hu111, <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �.;� yr 'Q% Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> -�9 i i F;042 N�i <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> U%jp�— <br /> Facility(Mdress: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date. Manufacturer Training:Cs <br /> rim -?� - Cv-� 1 -1ci oV- 1 440.00-✓JIII-16 -le <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El❑ electronic Serial #: El hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <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 /> sensor <br /> ❑ ❑ positive shutdown Model: Primarypipingtesting at: <br /> ❑ fail safe Serial #: <br /> El NA _ minutes i <br /> sensor Secondary containment testing for: <br /> ❑ positive shutdown Model: (kms 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 /> ❑ NA 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 95110 ❑ 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 /> 310 iu Qcv* �94 _b L- © 1 3 P1 <br /> 2 <br /> rJ�C ► L <br /> THIS FACILIT IS SUBJE TO REINSP N AT A TIME AT EHD'S CUR ENT HOURLY RNA TE. <br /> EHD Inspect Received By' Ti <br /> URAL Nffi�_� <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />