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P0.U1ryr <br /> �o. .coG SAN JOAQUIN COUNTY <br /> 0W, <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .Z< <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209) 468-3433 Web:www.sigov.orq/ehd <br /> �q�IFOR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilityape: Inspection Date: <br /> 1 6Aa 10-1-is <br /> Facility Address: , Service Request#: <br /> Fiy� I I 'N <br /> Wk , 1,=0i!s- �) — jkl�e <br /> , C� <br /> Onsite Service Technician's Flame: ICC Service Tec niciaM Steller Exp.Date: Manufacturer Training: <br /> Iq <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 /> ❑ ' test ro rammed <br /> JnK7 �6 _ZPP, ensor <br /> ositive shutdown Model: 10t��11 Primary piping testing at: <br /> ❑ fail safe Serial#: ❑ 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 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 LIS letter 150-1) ❑ Other: see below <br /> Q r\ I .A <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> THIS F CILI S SUBJECT TO REINSPE TION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Ins p Re ived B : Title: r-'^ <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />