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OAQU F.N• <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ! ' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.orq/ehd <br /> \?- / <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit Name: Inspecti n Date:' <br /> Facility Address: Servi Request#: <br /> r4,15 10. 6 0111� I't e� ctl� 1 <br /> to Service Technic i n's Name: ICC Service Technician/Installer E p.D te: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: <br /> 11 line test programmed El Caldwell System ❑ Other <br /> sensor ,, n,I <br /> El positive shutdown Model: V �U Primary piping testing at: <br /> El❑ fail safe Serial#: psi <br /> ❑ NA minutes <br /> sensor Seco dary containment testing for: <br /> ❑ Elpositive shutdown Model: 7 UDC(s) Piping <br /> ❑ fail safe Serial #: Vjf1j± Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for he ab ve components are next due by: <br /> F-1Elpositive shutdown Model: % f <br /> ❑ fail safe .Serial #: Note: Please be are 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 /> J This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> } <br /> AA <br /> n h. - <br /> THIS FACILITY.IS SUBJECT TO REINSPECTIO T ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E In ect r: Receive y Title: <br /> 7117. <br /> YL SA4-611AA <br /> EHD A-04 UST SERVICE REQUEST INSPECTION RE ORT <br /> Rev 4/30/12 <br />