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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.sigay.orglehd <br /> CQLf F p�R�4P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> r <br /> Facility N me: Inspect' n Date: k <br /> Facility Addres : 5ervic� Request#: <br /> Onsite Service Technician's Name: ICC Service Technicifan/ stall Exp.Date. Manufacturer Training: <br /> N U 1 �Afz Z d N W <br /> SERVICE SERVICE <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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> Primary piping testing at: <br /> Ll positive shutdown Model: pi <br /> f; <br /> F-1 Llfail safe Serial #: ❑ minutes <br /> ❑ NA f; <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 21 containment components are required tote tested upon <br /> ❑ NA installation,6 morths atter,and every M months thereafter, <br /> ❑ <br /> o Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel � <br /> ❑ Drop tube with mechanical overfill at 95% <br /> ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Other: see below <br /> ❑ This UST facility is APPROVED to operate This UST facilit is NOT AP R ED to operate <br /> 2 <br /> t <br /> U ipj E <br /> I <br /> h.r L 5 ,RAJ Q ej C', <br /> THIS FACILITY IS SUB CT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD in ctor: L t R d Title; <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />