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QA4UtM C <br />a- E.�'•.a � 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'gov.orglehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />71 <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />F7 <br />Drop tube with mechanical overfill at 95% <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes j <br />9condary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Testing for th above components are next due by: <br />Note: Please he aware that 2° containment components are required to be tested upon <br />installation, 6 months akar, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />71 <br />Corrosion protection <br />a <br />❑ <br />Other: see below <br />This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br />Ei 23-04 <br />Rev 4130/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />