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�o. r.coG SAN JOAQUIN COUNTY <br /> Q. ENVIRONMENTAL HEALTH DEPARTMENT <br /> > � !. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.siaov.ora/ehd <br /> ,.4.�iFpRN/ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> g <br /> Facility Address: Service Request#: <br /> 13 3 c1 S <br /> R <br /> site Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> 01511A 1)oi" q l sl,L �q ���,v G�I� s�z� Vol <br /> SERVICE SERVICE <br /> Leak detector <br /> E] mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ F-1❑ electronic Serial #: El hour hydrostatic ElIncon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> 1:1 fail safe Serial #: ❑ psi <br /> I El NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ positive shutdown Model: -71 R UDC(s) Piping <br /> ❑ fall safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> El Elpositive shutdown Model: -a yn� � - n5 G,. --t ins-LGt l iri. c)e7 <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 LIS letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate >�This UST facility is NOT APPROVED to operate <br /> v mar hq mSTa1)(, on V f C 7/y <br /> Oil U""D vUe& <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> t I <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />