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'aAqu► SAN JOAQUIN COUNTY <br /> -�rri•'••oG - <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> INC <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 /> F•a�ci^lity Name: Inspection Date: <br /> 1 Y, <br /> CV � 1i / <br /> Facility A ess:_ '�j Se ce Request#: <br /> 4 ', ( (.c�c CA _5P()00 S <br /> t_ <br /> Onsite Service Technici n's Name: I ICIZ Service Technician/Installer Exp.Date: Manufacturer Training: <br /> ch � o vl n dI- I --I W i - c <br /> SERVICE SERVICE <br /> Leak detector Spill bucket L1 minimum 5 gallon <br /> echanical Model I Q 2-0c C) ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> El line test programmed <br /> Leak detector V--0r- V Spill bucket ❑ minimum 5 gallon <br /> mechanical Model: aQ OOa ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> El Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> [71NA minutes <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 /> ❑ fa i I 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) ❑ Other: see below <br /> XThis UST facility is APPROVED to operate T facility is NOT APPROVED to operate <br /> l \ W�) <br /> II i Q CSO! 0-U-1-, cx� <br /> L' <br /> - - <br /> U U lit V1 " - ID Lt/v <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: R ived By: _ Title: <br /> t- ci n_�2 <br /> fc: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />