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OP4ulN•C <br /> ).•.4G.t'•.O <br /> _: crr •.G SAN JOAOUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q: a <br /> N:ICA <br /> ?. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.si-ov.org/ehd <br /> cq��F'oRN�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: /fl ) Inspection ate: / <br /> 1�5 Ell <br /> Facility Address: Service Request#: <br /> 4V O L- 13/vd- 5ivri-inn i -SWOT I ota� <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> 8 / V X 3/2 It 5 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ 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 /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> El 1:1 psi <br /> ❑ fail safe Serial #: <br /> 11 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 2°containment components are required to be tested upon <br /> ❑ N A 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 LIS letter 150-1) Other: see belowp—( `C 0atc, � <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> 0&4 <br /> i old , <br /> ndjrl - <br /> /M ja,vz v� <br /> o e V <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: R ceived By: / Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />