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Op<IuIN'•.0 <br /> --mill SAN JOAQUIN COUNTY <br /> ;e- a ENVIRONMENTAL HEALTH DEPARTMENT <br /> t 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 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 /> Via; (0 -J'A-.10 1 1� <br /> Facility ddress: ervice Request#: <br /> Onsite Service Techn.InI s Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> `c2�[ — .. ry–22.CC71 TAt� Y� _ <br /> 1 hj _ �,gy 1- dal �i- <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial: ❑ El hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical Model r 15 Spill bucket Xminimum 5 gallon <br /> ❑ ❑ electronic Serial#: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System )(Other"h <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> ❑ El psi <br /> El fail safe Serial#: <br /> El NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: '6'1 i 1'Q UDC(s) Piping <br /> ❑ fail safe Serial #: E - Sump(s) - UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> El El <br /> positive shutdown Model: Ng ��S��yl' J1 (o ww <br /> ❑ fail safe Serial #-. kj;rkC LL <br /> NotePlease be aware that 20 containment components are required o be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. 4—'6r , , <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 U ix lo, le—o U, E <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> ffl `. <br /> s J— �1i IE�A� `L <br /> kA } ` L"L au <br /> THIS FACILI Y IS S B ECT TO REINSPECTI N At ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD InspegtonN Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />