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OP'•aulN• C <br /> SAN JOAQUIN COUNTY <br /> Q: •-+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> U): <br /> < <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.s4gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 81�: 0 1 —1 <br /> Facility Addr s: � Service <br /> Onsite v e echnicias N <br /> ' ame: ICC Service Tech niciaMnstaller Exp.Date: Manufacture.•l�l�r��Training: <br /> Zi 01 <br /> ISr <br /> SER ICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: ElEl1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: El El Spill bucket El minimum 5 gallon <br /> El El hour hydrostatic ❑ Incon TS-STS <br /> E] electronic Serial: <br /> El line test programmed El Caldwell System ❑ Other <br /> sensor Primary.pip►r;g tes i g a : r <br /> ❑ positive shutdown Model: p <br /> si <br /> El ❑ fail safe Serial #: minutes <br /> ❑ NA <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 L 51 V11 <br /> (1 -i & S b <br /> ballad J kn' I-P- d' ±m&yn) ,aj <br /> aw <br /> Ue <br /> �- 1 <br /> THIS FACILITY IS SUBJECT TO REINSPE I N AT A Y TIME AT EHD'S CURR T HOURLY RATE. <br /> EHD Ins r Rec e y: Ti e: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />