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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.oro/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> W 0 ))—)AD(�1 <br /> Facility Address: , Service Request#: <br /> [' <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp. Date: Manufacturer Training: <br /> @�c l� i�-li = � Nom �� -��rv►�-�s �3�l <br /> i ^ <br /> SERVICE SERVICE <br /> Leak detector <br /> 1:1 mechanical Model: Spill bucket 11 minimum 5 gallon <br /> ❑ <br /> El electronic Serial #: ❑ 111 hour hydrostatic 11lncon TS-STS <br /> El line test programmed <br /> Ll Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El electronic Serial: ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> ED line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> Priv piping testing at: <br /> ❑ positive shutdown Model: <br /> L <br /> 11 fail safe Serial #: minutes + 50ap je� <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model' b $ 11, JtDC(s) Piping <br /> ❑ fail safe Serial #: ump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: JA, <br /> ❑fail safe Serial #: Note: Please be aware that 2°containment components are required to be tested uccr <br /> ❑ NA nstailation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 9501c Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 9500 ❑ 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 /> Y moor ► r <br /> VO v- ect;ax 10 os2t CA- r <br /> L4 S' n eld a 121-1 <br /> 4 V10'15 <br /> L 0-0 <br /> v <br /> THIS FACT ITY IS SUBJ CT TO REINSPECITION AT ANY YIME Aj EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec eceved Title: <br /> �,+, � RiITS 4 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />