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oAa"tN .c SAN JOAQUIN COUNTY <br /> yi L 'i cNVIRONMENTAL HEALTH DEPARTMEN <br /> :. 186V cast Hazelton Avenue, Stockton, CA 95205-0232 <br /> a P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.siaov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> /)1, 9 / 13 / ., - <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Trainin -13 <br /> SERVICE SERVICE <br /> 441)'X-Set Leak detector y i Spill bucket ❑ minimum 5 gallon <br /> 11 mechanical Model: ! 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> electronic Serial#: UCaldwell System ElOther <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: ❑ El hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> 11 Caldwell System El Other <br /> '9T cunj sensor LT <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> El psi <br /> 11 fail safe Serial#: _ 3G <br /> ❑ 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 /> ❑ fa i I 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 operateL This UST facility i NOT APPROVED„to operate <br /> l 4 \Q <br /> r <br /> A S or <br /> S � <br /> C <br /> +eS � ;�?W(�&A has PW Amyl Sr f <br /> THIS FACT ITY IS SU JECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In ctor: Received B104f TUa Title: y <br /> EHD 23-0 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/ <br />