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uV 11 IN <br /> SAN JOAQUIN COUNTY <br /> N• 66A <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 4. 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 <br /> Telephone : (209 ) 468-3420 Fax: (209 ) 468 -3433 Web : www . sogov . org/ehd <br /> FORS <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> f� W CO C� -� 1 C) <br /> Facility Address : Service Request #: <br /> A 5 A Ac o <br /> Onsite Service <br /> , Technician 's Name : ICC Service Technician/Instal ate : Manufacturer Training : <br /> ` <br /> �JN-r V+�-t ��— I <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model : <br /> ❑ <br /> El electronic Serial # : El El hour hydrostatic ❑ Incon TS -STS <br /> El line test programmed El Caldwell System El Other <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 <br /> El ❑ positive shutdown Model : 11 psi piping testing at: <br /> El fail safe Serial # : p <br /> minutes <br /> El 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 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 rj <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Vs Ack cto <br /> 4 4a kka:h A ae d e ( S s exu <br /> i ( �e @':2,�CS I t� e yjvSVA6 <br /> 4L i <br /> 1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE , <br /> EHD Inspector: elved B Title <br /> Q ( ( V �R <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />