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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> a: -a <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> . P. Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.siaov.org/ehd <br /> 4G/F O'RN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Fact 1 y Address: ��� Servicg Request#: C.7 . <br /> Onsite Seorvice Te`c i 'an's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> VI 7-11 ii <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 El Incon TS-STS <br /> ❑ electronic Serial#: <br /> El line test programmed ElCaldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El positive shutdown Model: <br /> El <br /> El fail safe Serial #: El <br /> ❑ NA minutes <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 /> El E1 <br /> positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 2-containment components are raquired 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 /> L� This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> !� $ <br /> IN <br /> Ca lAD I / <br /> THIR FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT HD'S CURRENT HOURLY RATE. <br /> EHD In Received By: Title: <br /> LW-11 J <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />