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RQUIy <br /> SAN JOAQUIN COUNTY <br /> —i Gy ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> ;P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.or /q ehd <br /> 0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> ,Lodi M'e'Ma P-ios i 2012 <br /> Facility Address: Service Request#: <br /> SReO 6 3 1 + <br /> Onsite Service Technician's Name: ICC Service Technici /installer Exp.Date: Manufacturer Training: <br /> ae f a z®' V `+ t_lceAJ8 <br /> SERVICE SERVICE <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 /> 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#: minutes <br /> ❑ NA <br /> S t vac— sensor �Z®� Secondary containment testing for: <br /> ❑ positive shutdown Model: VR 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 /> s <br /> THIS FACILITY IS SUBJECT TO REINSPECTION ATA Y TIME A HD' URRENT HOURLY RATE. <br /> EHD I ector: Re Title: <br /> EH 23-04 UST SERVICE REQUEST INSPEC ON REPORT <br /> Rev 10/06/10 <br />