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OPQU1jv C <br /> �• -t'_o SAN JOAQUIN COUNTY <br /> Q• <br /> rr� a *ENVIRONMENTAL HEALTH DEPARTMENS <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> ORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> f5' 6 /3 <br /> Fac lity Address: Service Request#: <br /> -- 6oJ <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> s <br /> x- z _6 �v - 1- ls <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El electronic Serial: El 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed El 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 positive shutdown Model: ElPrimaps piping testing at: <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for <br /> El ❑ positive shutdown Model: UDC(s) J, rr-- 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: / � 7Z. 13 ! 1,41I/Y4%1 S-z <br /> ❑ fail safe Serial#: r <br /> Note: Please be aware that 21 containment components are req fired 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 /> JEOverfill <br /> Drop tube with mechanical overfill at 95% ElCorrosion protection <br /> prevention (see LIS letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD R 4#Ins pe Re 'ved�y: Title: <br /> VV,/—, VV, W � Lo'- <br /> EHD 23-04 L UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />