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O P�U I N•.0 <br /> SAN JOAQUIN COUNTY <br /> c. + ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. '. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.segov.org/ehd <br /> 4�/PORN; <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Nme: Inspection Date: <br /> o <br /> Facility Address: Ser ice Request#r: <br /> �IA5 <br /> Ons' Service Te nician's Name: ICC Service Technician/Installer Exp.Date: M nufacturer-1 06k It 11 '01&- .rai <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: 11 Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: 1:1 El hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: El Caldwell System 11 Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> 1:1 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 /> ❑ I Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> IS M <br /> This-��s APPROVED to operate ; is NOT APPROVED to operate <br /> j fir � S <br /> ,'n <br /> c..bi'bf- -rnatulQ ch <br /> � y <br /> r <br /> THIS ACILIT IS SUBJECT TO REINSPECTION ATIAWTIME At EHD'S CURRENT HOU LY RAT . <br /> feL!nL:- <br /> EHD Ins Received By: Title: <br /> Z��L I ��' .- , ,/. I/?":.i"-t' I <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />