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°''a�t ' • <br /> ?•'---+F'E''• SAN JOAQUIN COUNTY <br /> i--c'r-- •.GZ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> I� { 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siQov.org/ehd <br /> '�t1i~oR�i <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> o" <br /> Onsite Service Technician's Name: IC Service Technician/Instal er Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: p <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> E] ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic . Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> L4L*G-6 sensor Primary piping testing at: <br /> Z positive shutdown Model:\`V-U`jgH El _psi <br /> El fail safe Serial#: ,�" L9°4 minutes <br /> ❑ NA <br /> SOI"_jr 7-5�sensor Secondary containment testing for: <br /> J rpositive shutdown Model: -i3%r,4c UDC(s) Piping <br /> ❑ fail safe Serial#: It3C�, 1 7 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 /> A -C yX& l-- L c" <br /> Ai {- i_ssea <br /> THIS FACILITY IS SUBJECT TO REINSPEC'PON AT AYY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Re Title:ed By: : <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />