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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> t..sell 1868 East Hazelton Avenue. Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sogov-org/ehd <br /> fF R• <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Trd } ! r <br /> Facility Address: Service Request#: <br /> co <br /> Onsite Service Technician's Name: ICjjC, Service Tech ianl installer Exp. Date: Manufacturer Training: <br /> WD-rd \xWob <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: p <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic 1-7 Incon TS-STS <br /> ❑ line test programmed ❑ 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 containmentto ting f <br /> ® ❑ positive shutdown Model: UDC(s) 1� Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor X Testing for the above components are next due by: <br /> ❑ ❑ ,positive shutdown Model: 6^ cmS o-o", <br /> ❑ fail safe Serial #: <br /> 1:3 NA Note. Please be aware That 21 containment co onents are required to be tested upon <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) 1 IN Other: see below <br /> r <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> In t •. C_- J SC LWQ_ <br /> r <br /> THS FA TY IS SUBJECT TO REINSPECTION Al ANY IME AT EHD S CURRENT HOURLY ATE. <br /> EHD Ins or. Receiv By f Title: <br /> �Cr (R1 Jf /� <br /> r' <br /> El23-04UST SERVICE REQUEST INSPECTI l <br /> Rev 4730712 <br />