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O0"CL C <br /> SAN JOAQUIN COUNTY 40 <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.sidov.org/ehd <br /> ��IFOiRN\ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: , Inspection Date: <br /> �-i1 -If�o <br /> Facility Address: Service Request#: <br /> ,-� -Tczkk� Qo`-4 P-4 H <br /> O�Jn�sfite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> kv Z5 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El❑ electronic Serial #: El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor t. %&VAA <br /> ❑ p hive shutdown Model: �• �1D,)5 Primary piping testing at: <br /> Elfail safe Serial#: E] psi <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 /> ❑fail safe Serial #: <br /> Note: Please be aware that 2°containment components are required to be tested upon <br /> E] 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 /> viietj 9 9 -o e.::F <br /> V y \e4 <br /> Lae t iokoAz VELA l,Lwltusk- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AY EHD'S CURRENT HOURLY RATE. <br /> EHD Ins Re iv (� Title: <br /> k7.,tyjj C4 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPOP- <br /> Rev 4/30/12 <br />