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o�QU"!l� 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.sjgov.org/ehd <br /> d<i F'o iz. � <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> �'� bleu m 1k I�V I <br /> Facility Address: Service Request#: <br /> bu <br /> O Ite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> F-1 mechanical Model: Spill bucket L1 minimum 5 gallon <br /> El ❑ electronic Serial: ❑ El hour hydrostatic ElIncon TS-STS <br /> [I line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> F-1 mechanical Model: Spill bucket El minimum 5 gallon <br /> ElEl❑ electronic Serial #: ❑ 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> L1 Caldwell System ❑ Other <br /> gn-k\40- sensor <br /> Elpositive shutdown Model: ' Primary piping testing at: <br /> 71fail safe Serial #: j 3rf} ❑ psi <br /> minutes <br /> ❑ NA <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 to be tested upcn <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 /> El 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 /> s1�Fi 1a �► s� �►� cP (1C c: UA b4 vo ulF ,%,i ce- �assec <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: 1 Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />