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o.P�U(N••.0 <br /> �r SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> . c.. <br /> —d ,'.• P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sogov.org/ehd <br /> F;0 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request-#: <br /> Onsite Service Technician's Name: ICC Service Technician/Insta ler Exp.Date: Manufacturer Training: <br /> Z/ a 9 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial: El El hour hydrostatic ElIncon TS-STS <br /> L1 line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El electronic Serial: El El hour hydrostatic El Incon TS-STS <br /> E] line st ro rammed El Caldwell System El Other <br /> sensor <br /> Elpo itive shutdown Model: �9 Primary piping testing at: <br /> ❑ fail safe Serial #: ❑ psi <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 /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 2°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 LG letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> /� t 2 ►%�/' G! S�zlr du /"��2 /7� 124 O u 0-/-' <br /> t14 164,16ZDAil <br /> r <br /> v 8 P - S <br /> vez 'ed <br /> HIS FACT TTY IS SUBJECT TO REIMSPECTI16N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe p�0 / ) n Recejved y: Title: <br /> LW <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />