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O PO U(N••.0 <br /> �. �1 •.O <br /> 2.• _err .G SAN JOAGIUIN COUNTY <br /> Q' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s4gov.org/ehd <br /> A<<FORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> S atAA ' �j- q -2x01 <br /> Facility Address: Service Request#: <br /> bl4-a5 N'... Vac: C J VQ c !_Sp G0--:)Q Q 110 <br /> Onsite Service Technician's Name: ICC Service Tech nician/Installer Exp.Date: Manufacturer Training: <br /> l c tu�-1 i ilii t C, 1-b <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 /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial:: El 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System 11 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: q io I' z UDC(s) VQ,4,�,v�� �aPiping <br /> E] fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: �� caw�d , ci- er <br /> ❑ fail sane Serial #: Note: Please be aware that 2°containment components re 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 /> .1;02 C1 v - 5 �-S 5i J 2S -T e u d :0 2 <br /> 'S•� <br /> PSI <br /> THIS FACILITY IS SUBJECT TO REINSPE9TION TT ANY TIME AT i-D'S CURRENT HOURLY RATE. <br /> EHD Inspector: RecE� ByA\, Title-- <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />