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OP�uIN• C • • <br /> SAN JOAQUIN COUNTY <br /> : ENVIRONMENTAL HEALTH DEPARTMENT <br /> y � 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �q�IFpit��P <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.ora/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> S '-I <br /> Onsite Service Technician's Name: ICC Service Techniciantinstaller 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#: <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> E] ❑ electronic Serial: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> sensor <br /> El positive shutdown Model: El Primary piping testing at: <br /> ❑fail safe Serial#: psi <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 2°containment components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% f�K Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) FEI Other: see below <br /> ,Z' This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> SLpk& � A-- A <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Recei ed By: ee kt'�VLe. <br /> itle: _ <br /> C 'C� �C <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />