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SAN JOAQUIN COUNTY <br /> Q <br /> SINVIRONMENTAL HEALTH DEPARTMENTO <br /> y: { 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �Q,• _...P Telephone: (209)468-3420 Fax: (209) 468-3433 Web:www,sj ov.orQlehd <br /> UNDERGROUND STORAGE TANK {UST} PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 4_-3 _ f <br /> Facility Ad cess: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> �r <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line testprogrammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ ❑ fail safe Serial #: ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ <br /> El positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s} <br /> 12 NA <br /> sensor © Testing for the above components are next due by: <br /> ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: <br /> Note: Please be aware that 21 containment components are required to be tested upon <br /> E] NA <br /> 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) D Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> ' Q . <br /> THIS FACILITY IS SUBJECT TO REINSPECT N AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspe EHIRe Title: <br /> ,, <br /> 130!12 3-04 <br /> Rev 41UST SERVICE REQUEST INSPECTION REPORT <br /> Rev <br />