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SAN JOAQUIN COUNTY <br /> I ENv;R.oNMEN1TAL HEAL,H DEPARTMENT <br /> I 1868 East Hazelton Avenue, Stockton. Cl. 95205-6232 <br /> `.• ,i � Telephone:(209', ,468-3420 Fax: (209) 468-3433 Web:www.sigcv.cra end <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 Ser-4ice Technician/Installer <br /> {' �..,�. Exp.Date: Manufacturer Training: ` <br /> -S i� � <br /> SERVICE SERVICE <br /> ICE c� <br /> Leak detector Spill bucket ` minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial �t ❑ 1 hour hydrostatic C Incon TS-STS <br /> Elline test croorammed ❑ Caldwell System X Other <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ <br /> 11 mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial r: ❑ Caldwell System ❑ Other <br /> ❑ line test ororammed <br /> sensor <br /> ❑ <br /> El positive shuidcwn Mcdei: J Primary plping testing at: <br /> si <br /> ❑ fail safe Serial <br /> „, , minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial I#: 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 r�`r: Note: Please oe aware;hat 21 containment components are required to be tested uoen <br /> ❑ NA installation.a months after,and every 36•nonths thereafter. <br /> ❑ I Drop tube with mechanical overfill at 95% ❑ Cold star of monitoring pane! <br /> ❑ I Drop tube with mechanical overfill at 95'-o ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate b' This UST facility is NOT APPROVED to operate <br /> O'l..t 1v�.'.%,- �.y t' '! i.}S i C?1 j( (' �`�.�i- --''y.-� •.' .� `:-i` `' <br /> r - <br /> t� C�.p'�t. .. <br /> �AAQA- Ilia <br /> ffj ` t i <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector Received By: Title: <br /> HD 23-04 UST SERVICE REQUEST INSPECTICN REPORT <br /> ev 4/30/12 <br />