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O.P••QU IN.•.0 <br /> �� SAN JOAQUIN COUNTY <br /> Q. �+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> N 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> . c.. _� •'•• P Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> A�fROR�` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> G 1 ZGY <br /> Facility Address: Service Req est#: <br /> `� 1�- - l�l.X- R, s C3 C�c S <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <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 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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> Ll 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 LG letter 150-1) ❑ Other: see below <br /> This U T facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> \)�k m, `?L►' V1 4 t Y S -1 C1 C. C oW -44tlftV 1'W tip t` pW <br /> 1kta&vll5ev-W Mt Cl � 3m6-_-, - 411 kA5 <br /> v1 \zee ' eofv_' U CNN�vl_ty tit -kAll, "BI lt4 <br /> 6,45 *A - tivtA -6 CCA -- <br /> THIS FACILITY IS SUBJ T TO REINSP CTION AT ANY TIME AT E D'S CURRENT HOURLY RATE. <br /> EHD Inspect Receive, y Title- <br /> i <br /> 147 <br /> VV VVV WV U <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />