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OP43.14!!V•.0 <br /> SAN JOAQUIN COUNTY <br /> Q. -+ tzNVIRONMENTAL HEALTH DEPARTMENT <br /> N. < 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 /> R She, q-2o-2o i3 <br /> Facility Address: Service Request#: <br /> ` q 6titov,� <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 <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial: ElEl1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> El positive shutdown Model: ❑ Primary piping testing at: <br /> ❑ fail 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 /> ElNA 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 /> rE] 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 /> COyt+-QN 1-P, 10 <br /> a0 0 U DC C3 <br /> ODIC- <br /> 5 ' <br /> o� r cow �t C otos r1a�m <br /> CJ Q 2XeoW Q CO►�-r r � '� S C I <br /> QAA <br /> ►.� <,)P0_-_aer r r c - � a��p , BM.-Vo <br /> 9)490 2y-i-- <br /> T ,r Cit" t eV �t <br /> IS FACILITY IS SUBJECT TP-R€INSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Ree ived By: Title: <br /> EHD 23-04 J UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />