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OAQut�!. <br /> SAN JOAQUIN COUNTY <br /> r. ENVIRONMENTAL HEALTH DEPARTMENT <br /> w: i <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sAgov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> -I —RANQA_, v©Iq -1 14::5 <br /> Facility Address: Service Request#: <br /> Onsite Se ice Technician's Na e: ICC Service Tech nicianllnstaller Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket minimum 5 gallon <br /> ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System XOthe ,,�,,1 v Qve <br /> Leak detector <br /> ❑ mechanical Model.- Spill bucket Zminimum 5 gallon <br /> El Elelectronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System �OtherA ,�) v <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> El 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 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 /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> rvSi - ' 4C67tCtk <br /> - <br /> xQ —ploAc-vve <br /> oegicto t I1 S <br /> P) <br /> 1 - <br /> v <br /> C-0 e ,� v►P WA v,L4 eA c <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received Title: <br /> EHD 23-04 i{ UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 ��11 C)4 2__ <br />