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O.P.4 U 1.1y.•.t, <br /> SAN JOAQUIN COUNTY <br /> cr �+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • c.. _f _.'•• P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.segov.org/ehd <br /> R��FOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: r Inspection Date: <br /> RoJ �i ct IIA- 'm 15 <br /> 13 <br /> Facility Address: Service Reques #: <br /> Dd roic) SR-00 I <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector _ <br /> �{, ❑ mechanical Model: U � 4" �� Spill bucket El minimum 5 gallon <br /> �"l electronic Serial: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test <br /> El Caldwell System ❑ Other <br /> programmed <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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <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) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Lid C ' <br /> J• tA� <br /> *THISITY IS SUBJECT TO REINSPECTIONAT ANY IME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Received Title: <br /> EHD 23-0 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/ //v <br /> ��I <br />