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a�aufN SAN JOAQUIN COUNTY <br /> i=NVIRONMENTAL HEALTH DEPARTMENT10. <br /> ` <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �a�tFpR��P <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s'gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> y - i �) -i CC <br /> Facility Address: Service Request#: <br /> I -1 0.4 <br /> Onsite Service Technician's Name: ICC Service Technician nstaller 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 /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> F-1 ❑ mechanical Model: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: ❑ Caldwell System El Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> El positive shutdown Model: ❑ psi <br /> El fail safe Serial#: <br /> El 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 /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note Please be aware that 20 containment 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 LIS letter 150-1) ❑ Other: see below <br /> A This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> c1 `�► o� nc r <br /> S-t- 7 Cl S <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIM EHD'S CURRENT HOURLY RATE. <br /> EHD Ins clot: Recei Title: �- <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />