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AQU Ely <br /> 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.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> A <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician_/Installer Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System El Other , <br /> Leak detector Spill bucket ❑ minimum 5 ga!!,on <br /> F1 ❑ mechanical Model: El El El hour hydrostatic 11 Incon TS-S-i S <br /> El electronic Serial #: El Caldwell System El Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <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 /> ❑ 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% 0' Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ElOverfill prevention (see LG letter 150-1) F-1 Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> THIS FACILITY IS SUBJECT TO REINSPE4TION AT ANY TIME AT EHD-S CURRENT HOURLY RATE. <br /> EHD Inspect9r: Rec� d Tek; <br /> Q C . <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />