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Pa—o.F 'cp <br /> SAN JOAQUIN COUNTY <br /> z ^�� �r� ENVIRONMENTAL HEALTH DEPARTMENT <br /> yI X 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • •._� _''..,P Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.segov.org/ehd <br /> q�/FORS` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> T IA-bd 4C �;I�; 10 S- <br /> Iwtulit Address: Service Request#: <br /> W - "ewk <br /> Onsite Service Technician's Name: ICC Service chnician/Inst Her Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> E] mechanical Model: Spill bucket El minimum 5 gallon <br /> F] ❑ electronic Serial: ❑ El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <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 /> El El positive shutdown Model: ElPrimarps piping testing at: <br /> ❑ fail safe Serial#: p <br /> ❑ NA 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 /> ❑ fail safe Serial#: Note: Please be aware that 20 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 /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> l 4 t <br /> C <br /> THIS FA ILITY IS SUBJECT TO REINSPECTI AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receiv B Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />