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'oAQul(y CQ <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> q�fFOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST <br /> E US IN <br /> SPECTION REPORT <br /> Facility Name: Inspection Date: <br /> voods 6� zks tA or- <br /> FacilityAddress: Service Request#: <br /> 41 ()6 Ci C.-�LH <br /> Onsite Service Technician' Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> 1 1 <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 <br /> El positive shutdown Model: ❑ Primaps piping testing at: <br /> ❑fail safe Serial#: <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 /> ❑fall 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 /> P n <br /> 1AI 2C Lt C <br /> m <br /> LA) <br /> LAJ <br /> w <br /> -ka's 15:�* . I <br /> c <br /> HIS fIAALITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I s ector: Rec ' ed By: Title: <br /> EHD 2 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/3 12 <br />