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ip <br /> SAN JOAQUIN COUNTY <br /> `/ENVIRONMENTAL HEALTH DEPARTMENT1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sioov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facili Name: �,t r, � //\ <br /> InsP tioi)-pate: <br /> Facili Address: S ice Requ St#: <br /> ties �. Ice <br /> Onsite Se ice Technician's Nam ICC Service Techninstaller Exp.Date: Manufacturer Training: <br /> .C1*6V hw�, 11-1A-1; cia <br /> 4 24- <br /> SERVICE SERVICE <br /> Leak detector i I 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 TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> El positive shutdown Model: ❑ psi <br /> ❑fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall 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 2°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�e. laNs t <br /> rx C WArm- <br /> QAL k5 <br /> I , <br /> IS IL 1 B, ECT REINSP CTION At ANY TIME T D'S CURRENT HOUR RATE. <br /> EHD Inspector I Received Bv:// Title: <br /> EHD 23-04 �� UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />