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SAN JOAQUIN COUNTY <br /> N + ENVIRONMENTAL HEALTH DEPARTMENT <br /> �I> y .� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c `P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service FTequest#: <br /> (D3 " hl k60 <br /> Onsite Service Technician's Nam IC Service Technf Dae:fan/Installer Exp., Manufacturer Training: <br /> J l <br /> SERVICE SERVICE <br /> Leak detector Sl. <br /> El mechanical Model: '-- <br /> pill bucket minimum 5 gallon <br /> F-1 ❑ electronic Serial #: El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detectorSi. —Spill buc et minimum 5 gallon <br /> ❑ [I mechanical Model: ❑ Lg1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ 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 /> ❑ 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 /> El NA installation.6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 950% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) rEl—rOther: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> L <br /> suIn 4A <br /> dV <br /> 'L A�" s 1. S��k-I�—, ��, ,�+,✓ (ye,✓�/�e�/ a dd <br /> TAS FACILITY I SUBJECT TO REINSPECTt N AT ANY TIME AT EHD'S URRENT HOURLY RATE. <br /> EHD Inspector. Rec ved By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />