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oA4u--�c SAN JOAQUIN COUNTY <br /> Q I 2` ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. Imo' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �l or. Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> 9t/.raRtJ, <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Reques #: <br /> ( 4-b S C-P (. I 12 N l cz=�T SILC) O '�-ej + <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: t/T— 102 _ L(S) <br /> C A-V�s 1 �o�ZZr-1 5 Z `� I b Pw 4 Z�S 141 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: � Spill bucket minimum 5 gallon <br /> F-1 El electronic Serial #: !p" 1 hour hydrostatic ❑ Ikon TS-STS <br /> El line test programmed El Caldwell System Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El❑ electronic Serial #: 111 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <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 /> f „} This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Veld ti <br /> r� rr fr 3 d Wt' <br /> THIS FACILITY IS SUBJECT TO REINSPECTIO AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: ece Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />