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Pq•U I/y <br /> °' co SAN JOAQUIN COUNTYto <br /> r c <br /> ONVIRONMENTAL 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�/FORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Nairne: Inspection Date: <br /> s r <br /> V,WW10 1,14(AM-C <br /> Facility Address: Service Request#: <br /> r <br /> Onsite Service Technician's Name: BCC Service Technician/Installe Exp.Date: Manufacturer Training: <br /> V,-" j <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> � mechanical Model: L- - ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System El 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 /> ❑ ❑ positive shutdown Model: Primaps piping testing at: <br /> El <br /> ❑ fail safe Serial#: 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 2°containment components are required to be tested upon <br /> ❑ NA Iinstallation,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 /> r <br /> ® 1-s XC l t tjA <br /> AAAA _VM Lf niowY' r P <br /> Y <br /> row <br /> I � <br /> t tc <br /> THIS FA ILITY IS SUBJE T TO REINSPECTION AT ANY TIME AT EqDS CURRENT HOURLY RATE. <br /> EHDIn r Received By: A-',, Title: <br /> EHD 23-04 \ 1G zCy RERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 (I <br />