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O.P4 U I N••.0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sogov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> hr-cx <br /> �- <br /> Facility Address: Service)Zuest# <br /> "T 0�q " L I <br /> Onsite Service Technician's Name: ICC Service Tec nician/Installe Exp.Date: facWIN G- fiw/cturer Training: <br /> S c t? <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ❑ 111 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model:❑ El psi <br /> El 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 I 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) X Other: see below l t?c ( (� <br /> ❑ This UST facility is APPROVED to op rate This UST facility is NOT APPROVED to operate <br /> oil <br /> c n c: r 'CC-- V?LX 604-) C11i <br /> l1 �}1 <br /> D�% <br /> r i5 R cti, �X n Mew <br /> - <br /> )MA <br /> 0 <br /> THIS FACILITY IS SUBJECT TO REINSPEC ION AT ANY IME AT EHD'S c1jRRENT HOURLY RATE. <br /> EH ctor: Receiv6d By:�_ Tit! <br /> _;� _ <br /> EHD 23-04 ti►d ( �1��`7 V�7Fi"Vtnf(erl i1 7 G�T�6EI1 I NSPECTION REPORT <br /> Rev 4/30/12 <br />