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OPp.0 I/y r <br /> �•'�_ a SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> �i <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.siaov.org/ehd <br /> C��ikpai�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> 1"�,L - + -� <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> 1 �0 Q- -2-6f <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El❑ electronic Serial #: 1:11 hour hydrostatic ElIncon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> 11 mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El 111 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System E] Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <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) Py Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> N GAk ' 0 P/ c k,' _ r ~ cc, a-�A <br /> cd— <br /> b5-k, �- r I?N I ' <br /> OA a;6 U4 <br /> WA 4AICA v AA n <br /> -teat <br /> � �� UVJ�I LS �1/" �-✓ <br /> THIS FACILIT IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CU RENT HOURLY RATE. <br /> EHD rIctom(� Received By: Title: <br /> arALL <br /> E-U2062 #1 <br /> EHD 23-04 ^ UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />