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? * :� SAN JOAQUIN COUNTY No/ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigoy.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> r 0 c C q — —I <br /> Facility Address: Service Request#: <br /> k1� f C-> c0. e <br /> Onsite Service Technician's-Name: ICC Sam echniclan/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: ❑ Caldwell System 11 Other <br /> L3 line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System 1-1Other❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: ❑ <br /> — <br /> ❑ ❑ fall safe Serial #: psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fail safe Serial#: Sump(s) <br /> ❑ NA UST(s) <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note Please be aware that 20 wntamment components are required to be tested upon <br /> ❑ NA 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) ❑ Other: see below <br /> 1P This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> QiN 5 (\ 0 <br /> S <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Re ived By: Title: <br /> EHD 2344 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />