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CA4U�N�C� <br /> SAN JOAQUIN COUNTY <br /> e. ENVIRONMENTAL HEALTH DEPARTMENT <br /> �.bo <br /> I 'I 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c P% Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> q,4 b S �6� ��cl-� 5ie- Qo jq 9 2�j <br /> Onsite Service Technician's Na ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> mio5 Vp -( <br /> 'aZl-20 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El❑ electronic Serial #: ❑ 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ El positive shutdown Model: ElPrima Primary testing at: <br /> si <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <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 #: Note: Please be aware that 2°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 LG letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to opera t�dropJ f ❑ This UST facility is NOT APPROVED to operate <br /> bi -b voj-\/p 10- <br /> b ��Alf CakPA22ft)�u ,-, t.-X lisioad t-4 <br /> v for ( e• is <br /> V4 ; <br /> bi <br /> v✓c� k� Z�• �5 —b�u.f�- — c�-� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec or: Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />