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OA u—\C <br /> SAN JOAQUIN COUNTY <br /> q � ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Da e: <br /> if /°01WIle <br /> Facility Address: Service Request#: <br /> 32nD vV. f�Q-i'YI�12Q,�' �'7� c� Ck SA?00-7e? ,32 <br /> On it Servic Technician's Name: ICC Se vice Technician/Installer Exp.Date: Manufacturer Training: <br /> a� -l� oon& 2s 19 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El electronic Serial #: ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> 11 line test programmed <br /> ❑ Caldwell System ❑ Other <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 <br /> El El positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> El 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 /> El 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 �j,�cf�-r lGQJ <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> l-� 07'1 <br /> ) L V C-4-- <br /> THIS FACILITY SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect s Rec ived By: Title: <br /> eePs-vrGe i <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br /> r <br />