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;.:.._.�;.,_.. .� SAN.IOAQUIN COUNTY <br /> y� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sidov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 1� N <br /> Facility ddress: Service R s : <br /> 5VeQ-+ 11(10 <br /> ault_ 3 <br /> Onsite Service Technician's Name: ICC S rvice Tech ' ' !Installer Exp.Date: Manufacturer Training: <br /> S ' �� 0 - <br /> SERVICE <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El mechanical Model: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed El Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: El Caldwell System El Other <br /> ❑ line test programmed <br /> sensor <br /> F-1 ❑ positive shutdown Model: Primary piping testing at:❑ fail safe Serial#: El 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 LG letter 150-1) Other: see below'T <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> AD &Cowvle L Lt. o kAot ct n" "VNek-c) <br /> NOW 0 1� awd, r"k C6 14 OXM i t Ni g 4 CIO.: <br /> A . \&16A * u Cti 1 yr <br /> Vw <br /> 5 Artu <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins Receiv yJill' rI, Title: <br /> c <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />