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oAqutry. �1\V � I "V <br /> ''—�``-•,c SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ` Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 4-0( 3—/9 20 <br /> Facility Address: Service <br /> ''Request#: e <br /> Onsite S rvice Technician's Name: ICC Se is nicianllnstaller Exp. ManufacturerTraining( �. �I <br /> �X JV <br /> SERVICE SERVICE <br /> Leak detector Spill bucket L1 minimum 5 gallon <br /> E] ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket El minimum 5 gallon <br /> EI ❑ mechanical Model: p El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ —psi <br /> ❑ fall safe Serial#: <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: vV <br /> ❑ ❑ positive shutdown Model: �DC(s) Q -Piping <br /> ❑fall safe Serial #: ump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: NotePlease be aware that 2°containment components are required to be tested upon <br /> ❑ NA irate lla6on,6 mori 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 /> 3 tv uu D Tallsq- 32 pm <br /> R I R 5VIA lP �— 17 {� <br /> a STP — �.S 1� S" <br /> 11D. 10. 1 1 C <br /> ,( 12 <br /> THIS FACILITY IS SUBJECT TOR INSPECTI N AT A TIME AT EHD'S CURREN OURLY RATE. <br /> EHD Inspector: R iv d Title: <br /> n, �Flrt Mil/' <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />