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PQUtIy <br /> �o.• _caG SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMEN a <br /> •,Z <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK (VST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Na _ Inspection Date: <br /> 00 <br /> Facility Address: Servi equest#: _ <br /> RA+Pdoo 9 _�r�'Vm sk (2 0 L <br /> Onsite Service T chnician's Name, ICC Service Tech nician/I 6ser�xp.Date: nulact�er Training: <br /> rb� <br /> SERVICE SERVICE <br /> Leak detector <br /> mechanical Model: J Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: 171 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <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 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 <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> /ea 4- _E� - n /:> A <br /> T FACIWY&4S SUPJECIT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHDInsp for Receiv y: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />