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o.?°�I N••.c <br /> SAN JOAQUIN COUNTY <br /> Q. �+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> N1..1K 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> . P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s*gov.org/ehd <br /> F0 <br /> UNDERGROUND <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> 315' L-:�- �/J,0� -r I!-,z, <br /> Onsite Service Technician's Name: ICC Service Technician/InstaIler Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial:: El 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial El El hour hydrostatic El Incon TS-STS <br /> 11 line test programmed El Caldwell System El Other <br /> �" sensor V c.�,. Primary piping testing at: <br /> ❑ posi ive shutdown Model: X12 ❑ psi <br /> ❑ fail safe Serial #:��00 2U--��F <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 Iinstallation,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 /> THIS FACILITY IS SUBJECT TO REINSPECTION ATA Y TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp r: Receiv By: '7 A /J Title:. <br /> , 3 v � . <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />