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0.?'•4U I N••.c <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.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Insuction Date: <br /> Facility Address: ( Service Request#: <br /> g VW � 6-7 56 <br /> Onsite Service Technician's Name: ICC Service Te nician/Installer Exp. Date: Manufacturer Training: <br /> M �� <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial: El 1 hour hydrostatic 13Incon TS-STS <br /> ❑ line test programmed <br /> [I Caldwell System ❑ Other <br /> Leak detector <br /> E) mechanical Model: Spill bucket El minimum 5 gallon <br /> E] ❑ electronic Serial: El 1 hour hydrostatic ElIncon TS-STS <br /> El Caldwell System ❑ Other <br /> line test programmed <br /> sensor <br /> positive hutdown Model: VK— 3" Primary piping testing at: <br /> Elfail safe Serial #'L ❑ psi <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 /> ❑ fail safe Serial #: Note. Please be aware that 21 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 /> (r <br /> G L41 <br /> CY ajAr <br /> rz <br /> THIS FACILITY IS SUBJECT TO REINSPE910N,,AT A TIME AT EHD'S CURRENT HOURLY RATE. <br /> C <br /> ctor: R i d B Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />