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O PQ U r NSC <br /> -\; t `` SAN JOAQUIN COUNTY <br /> Q. ? ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 <br /> c 4i Telephone: ( 209 ) 468 - 3420 Fax: (209 ) 468 - 3433 Web : www . sigov . org/ehd <br /> � LtFOR �' <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> Facility Address : Service Request # : <br /> 6005 N DailLA 6 6+re t It .SAV �� 003 O3 <br /> Onsite Service Technician ' s Name : ICC Service Technician/Installer Exp , Date : Manufacturer Training : <br /> GINNIE III III 111 1 ; OWNS ;;I ME ; <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model : El El hour hydrostatic ❑ Incon TS STS <br /> El electronic Serial # : El Caldwell System El Other <br /> El line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model : ❑ ❑ 1 hour hydrostatic ❑ Incon TS - STS <br /> ❑ electronic Serial # : ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at : <br /> ❑ ❑ positive shutdown Model : 4 5bsi <br /> El fail safe Serial # : p ic�- <br /> ❑ NA _ minutes <br /> sensor Secondary containment testing for : <br /> ❑ ❑ positive shutdown Model : Gtr +\/ tAfff UDC ( s ) Piping <br /> ❑ fail safe Serial # : Sump ( s ) UST ( s ) <br /> ❑ NA <br /> sensor X Testing for the above components are next due by : <br /> ❑ ❑ positive shutdown Model : <br /> ❑ 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 LG letter 150 - 1 ) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> v yr �- CGv v i A kau r ttttttIII <br /> m � �t 2.r �aAr i <br /> i 11 - C cu ',d Q, -� encr <br /> THIS FACILITY IS SUBJECT O REINSPECTION AT D IME AT EHD ' S C1 IRRENY HOURLY RATE . <br /> EHD Inspector: Received By : <br /> 01a vj <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/ 12 <br />