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OP�'u'I N••.0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> cq�iF'oar'�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> N5�0 -W fAl 0 1 — I b-- 14 <br /> Facility Address: Service Request#: <br /> 9e <br /> Onsite Service Tichnician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer(Training: <br /> •M (Z1W 011 LH L <br /> SE VICE SERVICE <br /> Leak detector <br /> E] mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El El❑ 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: ElEl1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System 11 Other <br /> sensor VPMSnutes piping testing at:El � rycl <br /> Elp Elositive shutdown Model:El NA 0 fail safe Serial #: t <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 /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate ] This UST facility is NOT APPROVED to operate <br /> r & ff <br /> � © 1 <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 />