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OPp•U I N••.0 <br /> SAN JOAQUIN COUNTY <br /> Q. -+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. '. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sl-ov.org/ehd <br /> q�F p R? <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> P <br /> Facili y dress: Servic Reque <br /> I � � � � � <br /> Onsite Se ice Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Trainin <br /> t r r�t� 4tM lW& �, 1 t-71 n! V 6 714 4- <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El El hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial: El El hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor Primary piping testing at: <br /> El positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <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 20 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 LIS letter 150-1) ❑ Other: see below <br /> ThisU6:Faeil+t-Jl is APPROVED to operate i# is NOT APPROVED to operate <br /> - L4 A i S <br /> 022A 4— i Vt <br /> L oC44C L <br /> t S' <br /> THIS FACILI Y IS U J T TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe Receive B Title:.— <br /> M�2= <br /> T'OjRmu <br /> EHD 23-04 \ UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />