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Rp1A <br /> SAN JOAQUIN COUNTY <br /> �cNV <br /> IRONMENTAL HEALTH DEPARTMENI� <br /> ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> _ Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.siqov.org/ehd <br /> • •�4G%FORN`� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> Facility Address: Service Reclyllist : <br /> Onsite Service Techn . n's Name: ICC ervice Tec iciaNlnstaller Exp.Date: Manufacturer Training• <br /> QS a 2 <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 /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ _psi <br /> ❑ fall safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment to tin for <br /> ❑ ❑ positive shutdown Model: UDC(s) iping <br /> ❑ fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for he ab ve components are next due by: <br /> ❑ ❑ positive shutdown Model: 3 <br /> ❑ fall safe Serial#: Note: Please be aware Nat 2°containment components are required to be tested upon <br /> ❑ NA nstallation,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 /> L'i,hzoI <br /> ❑ This UST facility is APPROVED to operate Thi--1 OT APPROVED to operate <br /> /r o <br /> ass i h VGIt t <br /> t � , <br /> v <br /> THIS FAC TY IS SUBJECT TO REINSPECT RN AIVY TIME A S CURRENT HOURLY RATE. <br /> EHD pector Rete' d Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />