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f <br /> 'oPqu'N•.c® <br /> 2. �I&,— :Z SAN JOAQUIN COUNTY <br /> c. ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> • ;� Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.siaov.org/ehd <br /> ���FORa <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Flame: Inspection Date: <br /> g <br /> Fact ity Address: Service Re uest#:jj <br /> /e <br /> Onsite Service Technician's a e: Ic stellar xp.Date: Manufacturer Training: <br /> a 41 e�e <br /> i <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ther <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> sensor <br /> El El positive shutdown Model: ElPrimary piping testing at: <br /> si <br /> ❑fail safe Serial #: p <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 I 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 USTfacifitv i o NOT AP ROVED to <br /> R <br /> THIS FACIL S SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD In tor: Received By: . Title: <br /> -41 <br /> C'. <br /> EHD 23 04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />