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SAN JOAQUIN COUNTY <br /> ?_ r ENVIRONMENTAL HEALTH DEPARTMENT <br /> y �I <br /> .l 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> v Q% Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> cAi`� tANUL I A kc- c-Vcc,�c- , I-- <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service TechnicianlInstaller Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ 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 /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> ❑ —60 psi <br /> El fail safe Serial #: <br /> El NA 3D 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 /> A-0 k,5S Cr v i <br /> ' S1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector Received By / Title: <br /> 0yo— <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />