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oPg"fN c SAN JOAQUIN COUNTY <br /> c. 'a ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ' , P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.slgov.org/ehd <br /> F:0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility ame: Inspection Date: <br /> Facilitydd ss: Service Request#: <br /> CIA or <br /> l <br /> Onsite Service Ajq�Tech ici n N e: ICC Serv'ce Tech iciaNlnstaller Exp.Date: Manufacturer Training: <br /> V ` y / <br /> SE VICE SERVICE <br /> Leak detector �; <br /> ���i ��'� Spill bucket ❑ minimum 5 gallon <br /> mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: Sq 11 Caldwell System El Other <br /> / El line test ro rammed y <br /> ' Leak detectorSill bucket Elminimum 5 allon <br /> mechanical Model:Vio'-L"6i % p g <br /> El electronic Serial #: ��< ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ! El Caldwell System El Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> 11 fail safe Serial #: <br /> 11 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 2°containment components are required to be tested upon <br /> ❑ NA Iinstallation,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 /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> i i <br /> �j v. <br /> ,/ <br /> THIS F I T S T EIN ECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: y f?� I-RIceived/Fikh / Title: <br /> ff <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />