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O.P'•4uIN• C <br /> SAN JOAQUIN COUNTY <br /> NQ.Wt�' aENVIRONMENTAL HEALTH DEPARTMENT <br /> '. <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s'-qov.org/ehd <br /> q C i F p'iRt•>, <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> M 0 1 - I•I._I <br /> Facility Address: Service Request#: <br /> site Se ice chnici�anry's Nam : ICC Service Technician/Installer Exp.Date: Manufacturer T j g: <br /> t II CMZ � t"Z l�i�`' u�'ll4'I 4 <br /> _ i <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ElEl❑ electronic Serial #: ❑ 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial #: ❑ El hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor Primary piping testing at: <br /> ❑ <br /> El positive shutdown Model: psi <br /> ❑ fail safe Serial #: ❑ minutes <br /> ❑ NA <br /> sensor Secondary containment testin for: <br /> ❑ ❑ positive shutdown Model: UDC(s)V G Ip g <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA C' , f�, �I VVS <br /> sensor Testing for the above comtr hips kre n�Xt 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 LG letter 150-1) ❑ Other: see below <br /> t� S <br /> tis APPROVED to operate ] l itis NOT APPROVED to operate <br /> S r f f1AA n ri I r2VT1f i I >r <br /> r b uV . <br /> It <br /> MTHISILITY IS SUBJECT O REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> Received By: Title: <br /> L/ <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />