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?•'--¢�'•4� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ` Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s' ov.or /ehd <br /> L�FOR <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspeciton Date- <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Servi a Tech nicianti nsialler Exp.Date: Manufacturer Training: <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 proarammed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ D mechanical Model: ❑ p 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: psi <br /> El fail safe Serial #: s <br /> EJ NA minutes <br /> sensor Secondary containment testing for: <br /> El ❑ 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 /> ❑ fall safe Serial#: Nota: Please he aware that 21 containment components are required to.be tested upon <br /> ❑ NA Installation,6 months alter,and evaq 36 months lhereafler. <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 /> I07 <br /> s <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD ins ctor:,` Received By: Title: <br /> 2i <br /> EHL]23-04 UST SERVICE REQUEST INSPECTION AEPORT <br /> Rev 4130112 <br />