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oPp, u IN• • .c <br /> SAN JOAQUIN COUNTY <br /> Qr ; •a ENVIRONMENTAL HEALTH DEPARTMENT <br /> N . 1868 East Hazelton Avenue , Stockton , CA 95205- 6232 <br /> et 70 <br /> ON to <br /> 4 69 Telephone: (209) 468-3420 Fax: (209) 468 -3433 Web: www . siaov . org/ehd <br /> A � 1 0 <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date <br /> 2o20 <br /> Facility Address : ,, Service Request #: <br /> Pvcjhr S,400ngoG ae� <br /> Onsite /Service Technician 's Name : ICC Servi Lcian/Installer Exp. Date : Manufacturer Training : <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model : ❑ ❑ 1 hour hydrostatic ❑ Incon TS- STS <br /> ❑ electronic Serial # : El Caldwell System ❑ Other <br /> ❑ line test ro rammed <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 Elpositive shutdown Model : El psi <br /> El fail safe Serial # : p <br /> minutes <br /> El 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 /> ❑ 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 <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> L. <br /> - ON107 <br /> ` Z <br /> NIP <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE , <br /> EHD Ins ctor: Received By: Title: <br /> m, <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />