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? ' 000 �� SAN JOAQUIN COUNTY <br /> y` < ENVIRONMENTAL HEALTH DEPARTMENT <br /> '. 1868 East Hazelton Avenue , Stockton , CA 95205-6232 <br /> Telephone: (209) 468- 3420 Fax: (209) 468-3433 Web: www . sigov . org/ehd <br /> q � li= oR� <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> DIN coy) SADA C) a Gr 3 onm on <br /> Facility Address : Service Request #: <br /> AWL r Wbw\ r Wle 0 ak <br /> Onsite Service Technician 's Name: ICC Service Tech n an/Installe_ r Exp. Date: Manufacturer Training : r � <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 Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model : ❑ ❑ 1 hour hydrostatic ❑ Incon T&STS <br /> ❑ electronic Serial # : ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> ❑ positive shutdown Model : Primary piping testing at <br /> El El psi <br /> ❑ fail safe Serial # : <br /> ❑ NA minutes <br /> sensor Seconda toocontainment testing for: <br /> E] ❑ positive shutdown Model' Z 3 A1DC (s) 1 g c / I Piping <br /> ❑ fail safe Serial # : Sump (s) 7 UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by : <br /> ❑ ❑ positive shutdown Model : yywuk*rS � er I VII <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 /> Wommm <br /> ❑ This UST facility is APPROVED to operate This UST facil 'ty is NOT APPROVED to operate <br /> IAG\ ` �c c CLULOA a)(u -` o \�k.-r1't> <br /> , e 0'�1 <br /> y <br /> r � a ( V� on �- Imp �- <br /> PQo �L oto, . Q , <br /> THIS FACILITY IS SU JEC)r TO REINSPECTION AT A In [WEAT EHD ' S CURRENT HOURLY RATE . <br /> EHD Inspecto Received By. / Title: <br /> lekk(A %cu <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />