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�PQUfN. c 3 I ` 1 <br /> ?••�'�''•Oa SAN JOAOUIN COUNTY i <br /> rr� ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q: 'tip <br /> y? � 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.slgov.org/ehd <br /> oa� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Addres : Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exo.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ 11-mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <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 /> Pr <br /> positive shutdown Model: ,a ppiping testing at: <br /> El Elposi <br /> sitive <br /> safe Serial #: ���minutes A-1 ' W /'a- <br /> ❑ NA C rqLad <br /> sensor Secondary containment testing for: `�Ck <br /> ❑ ❑ positive shutdown Model: UDC(s) Sil q1 Pipings lrL_3 <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: �[} �'Y` C'+ tk)nik `lus�aLL <br /> ❑ fail safe Serial #: Note: Please be aware that 2°containmem 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 LIS letter 150-1) Other: see below <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> 3 <br /> _ <br /> pfk <br /> THIS FACILITY IS SUBJECT TO RE SPECT ON AT ANY TIME AT EHD'S CUR NTH URLY RATE' 4. <br /> EHD Inspect Received y� Title: <br /> y 1` ` (�\ <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />