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op4�I N•..c <br /> SAN JOAQUIN COUNTY <br /> Q. ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s'gov.org/ehd <br /> c9�iFOR�''�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> - I-7. <br /> Facility Address: Service Request#: <br /> I, ,te flee CSC CSD <br /> Onsite Ser vic Technician's me: ICC Service Technician/Installer Exp.Date: Man facturer Training: <br /> t�S C t�ST01) <br /> '�d%tel q !S �'' SDPyp <br /> OU <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ElEl <br /> Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: ❑ Caldwell System El Other <br /> El line test programmed <br /> I sensor <br /> Xfailpositive shutdown Model:Yq --32?) Primary piping testing at: <br /> safe Serial #:';7(1 ---M- <br /> ❑ NA Elmsnutes <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 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 /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> 1AA -n <br /> 0 Ul <br /> �6hy jib 64 <br /> 0 U1� <br /> 01 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> 00 E .In pe r: R eived B Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />