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�gtrtry <br /> SAN JOAQUIN COUNTY <br /> I±NVIRONMENTAL HEALTH DEPARTMENT <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 (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> TWk - c <br /> Facili iA s(s: Service Request#: <br /> Onsite Service Technicia 's Name: ICC Service T hnician/Installer xp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ ❑ 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 /> El ❑ mechanical Model: El ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed El Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ ❑ psi <br /> ❑ fail safe Serial#: <br /> ❑ NA minutes <br /> sensor S con a ontainment testing for: <br /> El positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above com onents are next due by: <br /> El positive shutdown Model: <br /> ❑ fail safe Serial#: Note: Please be aware that 2°containmen components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> E—Overfill <br /> Drop tube with mechanical overfill at 95% ElCorrosion protection prevention (see LG letter 150-1) ❑ Other: see below <br /> This UST facill is(APPROVED to operate El This UST facility is NOT APPROVED to operate <br /> J <br /> B <br /> P 0 <br /> )&:&e <br /> 4 �( <br /> I � 0 V <br /> <cp)ra CL-Au? , tp'aL Q'ua U-m"t"I Itn" <br /> n <br /> THIS FACILITY IS SUBJECT TO REINSPECTION A NY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receive y: Title: <br /> L IN �Q <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />