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��AgVI- <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ;w J 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ` Telephone:(209)468-3420 Fax:(209) 4-68-3433 Web:www.sigov.orglehd <br /> q ; <br /> UNDERGROUND STORAGE TANK {UST} PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Cate: <br /> Facility Address: Service Request#: <br /> Onsite So vice Technician's Name: ICC Service Technici n/Instailer Exp.Date: Manufacturer Training:' <br /> SERVICE SERVICE <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 /> Leak detector <br /> Ll mechanical Model: Spill bucket 171 minimum 5 gallon <br /> ❑ El El 11 electronic Serial #: 1 hour hydrostatic El ancon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> f C positive s�utuovvn Vcde`: ] psi y <br /> i ❑ fail safe Sarva! <br /> ❑ NA mi,nutes <br /> i <br /> sensor Secondary containment testing for: 1 <br /> ❑ ❑ positive shutdown Model: U=s! Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA LJ <br /> sensor Testing for the above components are next due by: <br /> ❑ positive shutdown Model: <br /> ❑fail safe Serial#: <br /> Note: Please be aware Ilial 2°containment components are required to be laded upon <br /> ❑ NA installation,6 months after,and every a5 months thereafter. <br /> D 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 C�C� This UST facility is NOT APPROVED to operate <br /> l•l � t f - <br /> ax-d LOW <br /> • 4� �..�-"'f +�'y r !!� '.•. <" - i i-, a, r gyp. - <br /> c f <br /> MIS FACILITY IS SUBJECT TO REI NSPECTtIOIN AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHl]Ins r_ Received 6y: Title: <br /> ENC}23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30112 <br /> . y/ <br />