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0 I\ • <br /> °' �'�� SAN JOAQUIN COUNTY <br /> cr �� ENVIRONMENTAL HEALTH DEPARTMENT <br /> N: 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c\'iFQaN%'; <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 Date* <br /> M X11�p('1 G I�SU /612.2 h <br /> Facility Address: (� Service Request#: <br /> / W vmaukod <br /> � �� +✓ <br /> Onsite Service Techni ian's Name: ICC erv'ce Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> E] mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> E] electronic Serial: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> ensor //J f��) <br /> Elpositive shutdown Model: Primary piping testing at: <br /> El psi <br /> Elfail safe Serial #: <br /> ❑ NA minutes <br /> ensor Secondary containment testing for: <br /> ❑ p sitive 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 S i <br /> ❑ This UST facility is APPROVED to operate XI.This UST facility is NOT APPROVED to operate <br /> r <br /> d 'i• «� r <br /> 0 <br /> v v<C_—/ /L/0. <br /> THIS FA,QkITY IS SUBJECT TO REINS CTI ANY IME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In ctor: d Title: <br /> EHD 23 04 US SERVICE RE EST INSP TION PORT <br /> Rev 4130112U.-X72'ek�)loan �nvt a C <br /> f��1r- i !'/,l aY� --ho,! i P-v d6es Yeo Wali . <br />