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oP,.gUtr!. <br /> ' '� 'Oy SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> j tl 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.orq/ehd <br /> 4�1FO¢ti <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Sh Lc - _�) `) -I <br /> Facility Address: Service Request J #//: ,, <br /> j—100r I W 7 L4 C <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 /> El ❑ mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> 11 electronic Serial #: <br /> ❑ line test programmed El Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El 1 hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> .0 7/B <<DL sensor <br /> El shutdown Model: �'�,- �� Primary piping testing at: <br /> El11fail safe Serial #: 1 I H b psi <br /> El 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 /> ❑ 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) R Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> (A ,l. <br /> v ,r C'-F 44 f, <br /> 01,�jp r I n�-e(IS+I _h 16 ILLi I-e kill <br /> �i <br /> �I -+���' ` • c_ p Je \ 'JCL .\\ <br /> THIS FACILITY IS SUBJECT TO REINSPECTIOOT A YITIME AT EHD'S CURRENT HO LY RATE. <br /> EHD Inspector: Receivedz 4 <br /> Ti <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />