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OP4u IN•.0 <br /> ).•.�,�G.E •.O <br /> _:• _�� .�\ AN JOAQUIN COUNTY <br /> Q. �IENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> r / Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.orq/ehd <br /> C��iFOR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Coh V!M 0 0-)-- l;)-- l <br /> Fa iii Addr ss: Service Request#: <br /> V6(l.VCT � <br /> sit Service T hniciin's Name: ICC ervic Technicia Installer Exp.Date: Manuf urgr Taj : O-1�'r <br /> M l U ` N v `l"{ <br /> kj I -,,A) lAr I --- 6 IL/-t VIL/ &1& !:�4 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial #: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> E] mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> El <br /> El fail safe Serial #: El psi <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 /> L1 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 /> F-1Overfillprevention (see LG letter 150-1) -01 Other: see below <br /> NC �- <br /> Thi, U TtfaciliDsty is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In r: Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />