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OPpUIN' • .0 <br /> kh s� SAN JOAQUIN COUNTY <br /> _: ri . 2 <br /> ar , <br /> , •� ENVIRONMENTAL HEALTH DEPARTMENT <br /> N': ' . 1868 East Hazelton Avenue , Stockton , CA 95205 - 6232V6014 See,* <br /> Telephone: (209 ) 468 - 3420 Fax: (209) 468 -3433 Web: www . s4gov . org/ehd <br /> soR�`P <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> T+1 <br /> y Name : Inspec ion Date : <br /> � k , Q � � �a a8 o6 <br /> Facility Address : Service Request #: <br /> 102 <br /> Onsite Service Technician 's Name : ICC Service/, Technician/lnstaller Exp. Date : Manufacturer Training : rS Sr 1 <br /> a l� � nn rG061 9 0 a D'} � V11 ZoZI <br /> SERVICE SERVICE <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 /> Leak detector + 2 <br /> El mechanical Model : Ii: Spill bucket Uminimum 5 gallon <br /> El ❑ electronic Serial : ❑ Vr 1 hour hydrostatic ElIncon TS - STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> Prima <br /> El ❑ positive shutdown Model : ElP piping testing at : <br /> si <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 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 /> S ift 4e ObJ;piwZ ck <br /> box, j -e Y.eE.. SPY )/ <br /> be <br /> e I qQijoijvowal' C <br /> QIP � Cry, A-GbbO r1betc-2.c e <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHp; Inspector: Rer5 ved By: Title <br /> ��/ <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />