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RECEIVED <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH3DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 MAR Q 2015 <br /> Telephone:(209) 468-3420 Fax:(209) 468 3433 Web;www.siaov.or /q ehd <br /> UNDERGROUND STORAGET (UST) PROGRAM SERVICET 1 <br /> Facility N me: In ction Date: <br /> %-A A, - ` <br /> Facility A does : Service-Request#: <br /> Onsite Service Technician's Name: ICC Service Tech nicia /Installer Exp.Date: INanuf rer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El - ❑ ❑ 1 hour,hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell'System ❑ Other <br /> ❑ line test ro rammed <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model:El ❑ p <br /> ❑fail safe Serial #: sl <br /> ❑ NA minutes <br /> sensor Secortary containment testing for: <br /> �. ❑ positive shutdown Model: � .�a UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> ti I., sensor Testing for the above components are next due by: <br /> !{ ❑ ❑ pa Sltl shutdown Model: <br /> �fail safe Serial#: <br /> ��,,, Note: Please be aware that 2°containment components are required to be tested upon <br /> uNA 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 /> T ' UST fac' 't ' APPROVED to operate ElThis UST facility is NOT APPROVED to operate <br /> AO IS C <br /> Q9)1ILMV�fOSAali <br /> t Vt __ t <br /> q gag$$ <br /> 9.�.. t, <br /> C" <br /> �✓ d { <br /> i �} <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EH® CURRENT HOURLY RATE. <br /> EHD Ins ctor: LReceiv y: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />