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SAN JOAQUIN COUNTY <br /> c a - ENVIRONMENTAL HEALTH DEPARTMEN4 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sioov.org/ehd <br /> �tFORa <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC S rvice Tec hnicianlInstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <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 /> ❑ ❑ positive shutdown Model: ❑ _psi <br /> ❑ fall 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 /> Wi ensor .fr' ❑ Testing for the above components are next due by: <br /> R'positive shutdown Model: V V- 7060 — Z <br /> .21ail safe Serial#: 711 Note: Please be aware that 20 containment components are required to be tested upon <br /> ❑ NA installation,6 months atter,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% ❑ 1 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 /> i P�v t <br /> � r <br /> a 5 <br /> 3 V i <br /> THIS FACILITY IS SUBJECT TO REINSPE911109tAT ANYTIME ATE 'S CURRENT HOURLY RATE. <br /> EHD Insp .—j Re ' e Titl <br /> EHD 23-04 'i UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 V <br />