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OAau I��•.C` <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ly. 1868 East Hazelton avenue, Stockton, CA 95205-6232 <br /> .P; Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.si4ov.org/ehd <br /> qGi' d� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> o q -4g -,).o(9 <br /> Facility Address: Service Request#: <br /> spw— <br /> Onsite Service Technician's Name: ICC Service Technicia /Installer Exp. Date: Manufacturer Training: <br /> nowod NOV - 1- 1- - <br /> SERVICE SERVICE <br /> Leak detector <br /> L1 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed 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: �11U i ly;n _testing at:— <br /> ❑ fail safe Serial #: /'C '���V psi ues <br /> ❑ NA minutes e <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 /> ❑ 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 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 /> - +D v <br /> TQQLSex a <br /> ~ (O <br /> PACU-4 <br /> THIS FACILITY IS SbBJECT 10 REINSPECTION A AT EHD'S CU RENT HOURLY RATE. <br /> spzr eczived 8y: Title: <br /> tiiD <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />