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°?a " t#go son N • 'c SAN JOAQUIN COUNTY <br /> ,G <br /> 2 �wtjNO 04 ENVIRONMENTAL HEALTH DEPARTMENT <br /> N , 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 <br /> Telephone: (209 ) 468-3420 Fax: (209) 468 -3433 Web: www . sogov. org/ehd <br /> 0060460 <br /> ipo <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> ro1D � �W � <br /> [ FacIIiWWddress : /ON ` � Service f <br /> Request # : <br /> Onsite Se vice Technician ' s Name : ICC Service Tec ician/Installer Exp. Date : Manufacturer Training : <br /> A laq Vo� JQ)zm�t ke), <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model : Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial : ElEl1 hour hydrostatic El Incon TS- STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model : Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial : ElEl1 hour hydrostatic ❑ Incon TS - STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> o <br /> El ❑ positive shutdown Model : El psi piping testing at: <br /> El fail safe Serial # : p <br /> El NA minutes <br /> sensor Secondary containment testing for / V(Z <br /> El Elpositive shutdown Model : UDC (s) -91, I , 4e Piping <br /> ❑ fail safe Serial # : Sump (s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above Qomponents are next due by : <br /> ❑ ❑ positive shutdown Model : ( j jI Q <br /> ❑ fail safe Serial # : Note: Please be aware that 20 containment components are required" t`o'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 /> VIIS k" <br /> — ion t o . SL - 1 , C;k a!: � <br /> 1 . <br /> 0 ; ` � NN <br /> ion I 0(u <br /> v <br /> D `, 1 _ ,\ <br /> THIS FACILITY ISS BJECT TO REIN . TtoblAT AN) TIME T EHD ' S CURRENT HOURLY RATE . <br /> EHD Inspector: G A Received By: Title : <br /> MENOMONIE <br /> EHD 23004 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />