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now <br /> AQU 1!y <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 /> \lFpR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> U � 5R�0 �a 3�� 5Ew � <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> O©Se <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 /> ❑ <br /> El mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: El Caldwell System El Other <br /> El line test programmed, <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: 3�J00o20 "�b3 4 <br /> TEl psi <br /> fail safe Serial17��� minutes <br /> NA 5MCE44 Seuh ` <br /> sensor Secondary containment testing for: <br /> ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: t rj L Sump(s) UST(s) <br /> NA 5 eit," <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note Please be aware that 21 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 (-Q q;ar <br /> Jlnl This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> "z O n a -Q y1. n lk�25 5A <br /> aaGr �_ Sc- q I ak5o r l ' u &a�� KD <br /> '52 8-4 SIP • <br /> O � c 1 Y c!j lz <br /> 2 . 00 ta` ',bi U s�=1 r <br /> THIS FACILITY IS S&BJECT TO REINSPECTION ATA Y TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec Rece d B Title: <br /> V�e�,�a n 0 <br /> EHD 23-04 ^ UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 (p)` <br />