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t n <br /> ?•''-•��''•9� SAN.IOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> i 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.si-ov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> iAV <br /> Facility A ss: Service Request#: <br /> 1-b vl �� - <br /> Onsite Service Technician's Name: [cc Service Technician Instat r Exp. ate: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> mechanical Model: �/ Spel <br /> 11l uc et minimum 5 gallon <br /> ❑ ISI1 hour hydrostatic Incon TS-STS <br /> ❑ electronic Serial#: ' \ ❑ Caldwell System �Othe� <br /> ❑ line test programmed OLA <br /> Leak detector <br /> mechanical Model: S <br /> El mechanical bucketinimum 5 gallon <br /> ElEl1 hour hydrostatic Incon TS-STS <br /> ❑ electronic Serial#: � ❑ Caldwell System y <br /> ❑ line test programmed XOther <br /> sensor <br /> El positive shutdown Model: El psi piping testing at: <br /> ❑ fail safe Serial#: p <br /> El 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: �j - <br /> El 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 LIS letter 150-1) ❑ Other: see below <br /> This UST facility is APP OVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> YY1\ yu,,(t9 a �O C t✓�L <br /> 90kkKLC'CAS (41 pj� n" <br /> v f *I C £In 0-0e — jX V),p 46 U 01 - <br /> T 3 <br /> THIS FACILITY IS SUIAJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect Received By: Title: <br /> V ', <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />