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OP�U IN'•.0 <br /> SAN JOAQUIN COUNTY <br /> Q. �+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> `. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.siclov.org/ehd <br /> cq<ikoR��P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> 3► s L� / S�L_-),o6-7 sG s <br /> Onsite Service Technician's Name: ICC 8ervice Tech nician/Installer Exp.Date: Manufacturer Training: <br /> be l `lp- V13/4 DPM s <br /> SERVICE SERVICE <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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El El El hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: El Caldwell System ❑ Other <br /> ❑ line test programmed _ <br /> 5 q- sensor V� Primary piping testing at: <br /> El positive shutdown Model: VGA• sw►s,�„- <br /> ❑Nail safe Serial #: v El psi <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 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) [3�t Other: see below <br /> _>27 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> s ,•s 11 J 1 6 <br /> 00 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp or- Received BY: Title- <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />