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O.P''4U I N••.0 <br /> ). � •.O <br /> SAN .IOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> C9c�FORN�P <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s'gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspecti476:�/ <br /> Unl�te - l a5 <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Servi echnicia ns a e xp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector❑ <br /> El mechanical Model: Spill bucket Elminimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El El <br /> mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: El Caldwell System El Other <br /> ❑ line test programmed <br /> sensor <br /> _ Primary piping testing at: erg( s c7a�t`es' <br /> El ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: psi <br /> ❑ NA �Q� 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 #: <br /> 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% LE <br /> 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 /> toitm- Z'cds.5-na 12 4a <br /> d riS P cb2 P16 -P -AL,-. 9 ods <br /> gzrz *J-4/t:S' <br /> THIS FACILITY IS ECT T INSPEC I Y IME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: I litle: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />