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Op'C•u IIV C <br /> SAN JOAQUIN COUNTY <br /> z �r� ENVIRONMENTAL HEALTH DEPARTMENT <br /> W, <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209) 468-3433 Web:www.sjgov.org/ehd <br /> hi <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fa il' N Inspec ' Dat <br /> Facili Addrs: �` �I LN Se�c�s©: <br /> Onsi a rvice hn is s Name: ICC Service Technician/Installer Exp.Date: Manufacturer T ming: <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 <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El El El❑ electronic Serial #: 1 hour hydrostatic F-11Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> F-1failsafe Serial #: <br /> [I 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 20 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)coma] rEll Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> try all &r t7444,, <br /> THIS F CI S J CT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Re ce ed By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSP CTION REPORT <br /> Rev 4/30/12 <br />