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oPQ•uIN,•.O <br /> �.• < •.oG SAN JOAQUIN COUNTY <br /> Q: ENVIRONMENTAL HEALTH DEPARTMEN <br /> N, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 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"K"1 Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service echnician/ all Exp. ate: Manufacturer Traini <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 ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> Primary piping testin at: <br /> El positive shutdown Model: psi <br /> � 1 j <br /> ❑ <br /> El fail safe Serial #: slG 1 <br /> ElNA c: minutes <br /> Cu �I <br /> sensor Secondary containnIent testing fol' <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 /> ❑ fa i I safe Serial #: Note Please be aware that 21 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 V"This UST facility is NOT APPROVED to operate <br /> Nit 2" <br /> THIS FACILITY IS SUBJECT TO REINS I T ANY TI AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe tor: / Rece y: j' Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />