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O p''4 U[N'•C <br /> Z. '°�, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. _ > 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> P. Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> =O 4 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> or q -4g <br /> Facility A ess: Service Request#:kf?O J2 <br /> Onsite Service Technician's Name: ICC Service Technicia /Installer Exp. Date: Manufacturer Training: <br /> �Q b'dA- I `t NOV - 1- q- - <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El❑ 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: P1%046 i piping testing at: –5-4 vgfor—K <br /> ❑ fail safe Serial #: hV psi v I� - <br /> El NA �IQ minutes _ loo( <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 21 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 pane! <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 /> V1 1 <br /> �. -Ero <br /> R.4l toy <br /> THIS FACILITY IS Si IRJECT f O REINSPECTION A AT EHD'S CU RENT HOURLY RATE. <br /> sper eceived By: Title: <br /> jQkQ (\AftAA2,Q AZT<"' P74,AA M— <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />