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°� auf 'v a 60SAN JOAQUIN COUNT`( <br /> Q: �I' ; � ENVIRONMENTAL HEALTH DEPARTMENT <br /> Nt. � 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 <br /> of of <br /> feel fee Telephone: ( 209 ) 468- 3420 Fax: ( 209) 468 - 3433 Web : www . sigov . org/ehd <br /> FORS <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION R 'EP `C) RT <br /> Facility Name : Inspection Date : <br /> Facility Address : Service Request # : <br /> I l <br /> tam IM e-r �(Xtk (yo a:::" Q <br /> Onsite Service Technician ' s Name : ICC Service Technician/Installer Exp. Date : Manufacturer Training : n/ov <br /> 04 <br /> SERVICE SERVICE <br /> Leak detector <br /> F1Elmechanical Model : Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial # : ❑ ❑ 1 hour hydrostatic ❑ Incon TS - STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> Spill bucket El minimum 5 gallon <br /> F-1 El mechanical Model : <br /> ElEl11 electronic Serial # : ❑ 1 hour hydrostatic Incon TS - STS <br /> El line test programmed <br /> ❑ Caldwell System [I Other <br /> sensorf <br /> Elpositive shutdown Model : Primary piping testing at : Cl l 00 UPC, <br /> ❑ ❑ fail safe Serial # : 0 Psi <br /> ❑ NA minutes <br /> sensor <br /> positive shutdown Model : econdar ontainment testin for <br /> ❑ <br /> ❑ p UDC ( s ) at Piping <br /> ❑ fail safe Serial # : Sump ( s ) UST (s ) <br /> ❑ NA <br /> sensor Testing for the above components areP �next due by : l <br /> ❑ ❑ positive shutdown Model : C - <br /> ❑ fail safe Serial # : �^ <br /> El NA Note: Please be aware that 20 containment components are required to be tested upon <br /> 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 /> s1 9t, w I h Y► Y1 cv So P� uO <br /> C cid \)'D ( ef. 5 <br /> C °I <br /> 5�0 <br /> e ve d . i rn CLA U e ' <br /> V) r I' <br /> �b s`► oa <br /> 15o �J a�� � 0 �' tQ, CCD Re%fe <br /> THIS FACILITY IS SUBJECTIrO REINSPECT AT ANY 1E AT END ' S URRENT HOURLY RATE - <br /> EHD Inspector: Recei ed By Title : <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/ 12 <br />