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OPQu ly. c <br /> ? '`''O� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y' 1 !, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ' • P Telephone:(209)468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> 0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> -1Zlev gva -C-71o► <br /> Facility Address: �L Service Request#: <br /> s r ` wTI- 0 m mk" lao44S'0, --i0o <br /> Onsite Service Technician's Name: ICC Service Techniciantinstaller Exp.Date: Manufacturer Training: <br /> ki V1 5 � aq- Ill vR; 5- -15 Will <br /> to oto <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 /> 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 I 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 /> --DAbiAt 40 VkXi A S sAWe w a col <br /> dors �1 hr L13 erg r � 4r-ems s <br /> �>Zu SO Ks 0-�R4e <br /> e s =41„ <br /> e to v✓ t Q aA- <br /> 15 I dDl cQ-rd �P-6 `GLS �- tam <br /> R8- (edmklTiMME <br /> U <br /> THIS FACILITY I SUBJECT TO REINSPECTION ATAT D'S CURRENT HOURLY RATE. <br /> EHD I ctor: n- 1 R �ved y: Title:lilMo <br /> A10 <br /> V <br /> EHD 23-04 UST SERVI E REQUEST INSPECTION REPORT <br /> Rev 4/30/12 �A ^� / 0 2 <br />