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0.?'•0.0 I N at <br /> ? ' � '•Oa SAN JOAQUIN COUNTY <br /> z ��� <br /> : ENVIRONMENTAL HEALTH DEPARTMENT <br /> ca <br /> y . > `:. 1868 East Hazelton Avenue , Stockton , CA 95205 - 6232 <br /> Telephone. (209) 468-3420 Fax: (209 ) 468 -3433 Web: www . slgov . orq/ehd <br /> cq� iFoR��P <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection D te : <br /> C �s v # <br /> Facility Address : Service Request #: <br /> 2 � 5 g Awelf 12d . , S'IV <br /> � <br /> Onsite Service Technician's Name: ICC Service T chnician/Installer Exp. Date : Manufacturer Training . <br /> ss <br /> SERVICE SERVICE <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 /> 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 Primary piping testing at : <br /> El positive shutdown Model : El psi <br /> ❑ fail safe Serial # : p <br /> 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 20 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 on cnbasa&gj <br /> t <br /> \ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Qn'th ed J aritYp Faaht 4won k /w ) e 10) vi 2 0 a4 5 <br /> OC t0 � r ( <br /> (W vDil bn !aA 1 2) )y <br /> THIS FACIL IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD ' S CURRENT HOURLY RATE , <br /> EHD I ctor: Rec ' e Bir. Title / <br /> l <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />