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1 <br /> ot,.4!IIY <br /> p� V1:D <br /> SAN JOAQUIN COUNTY 1 <br /> y 'j ENVIRONMENTAL HEALTH DEPARTMENT APR 1 2014 <br /> 1868 East Hazelton Avenue,.Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigoy.org7e HEALTH <br /> ---�,, I N ENTAL, <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST.INSPECTION R <br /> I <br /> Facility Na e: Inspection Date: <br /> Tr v - f <br /> Facility ddress: Service # <br /> 57 N h v <br /> On 'te ervice Techril an! Name: ICC Service T.echnician/Installer.Exp.Date: Manufacturer Training:' <br /> IA2M <br /> s - <br /> SERVICE SERVICE <br /> Leak detector it <br /> --- - ----�._:.--- - ❑. ❑ 1 hour hydrostatic----0-lncon TS=STS-- ---...._ <br /> electronic Serial#: ❑Caldwell,-System ❑Other <br /> ❑line test programmed <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ 1 hour hydrostatic ❑ Incon.TS-STS <br /> ❑`electronic Serial#: EI <br /> ❑line test programmed ❑Caldwell.System ❑Other <br /> sensor <br /> ❑ positive shutdown . Model: Primary piping testing at: <br /> ❑ ❑fail safe Serial#: C7 psi <br /> ❑ NA minutes <br /> i <br /> Sensor Secondary containment testing for: <br /> ❑ ® positive shutdown Model: UDC(s) Piping <br /> ❑fail safe Serial#: Sum s <br /> NA pO UST(s) <br /> El <br /> sensor Testing for the above components are next due by: <br /> F, ❑ positive shutdown Model: <br /> ❑fail safe .Serial#: Note: Please be aware that V containment components are required to be tested upon <br /> ❑ NA instaiiatlon,'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 1.50-1) ❑ Other:see below <br /> LIv This UST facility is APPROVED to operate ❑ This UST facility its NOT APPROVED to operate <br /> 1 C <br /> AtAY4 G VI & I'Vt <br /> R <br /> All <br /> tift <br /> FACILITY IS SUBJECT TO REINSPECTION AT ANYTIME ATE)IDS CURRENT HOURLY PATE. <br /> i <br /> EHD Ins a tor. <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT' I <br /> Rev 4/30/12 <br /> i <br /> - i <br />