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Aquiy <br />�o.• ca SAN JOAQUIN COUNTY <br />2= -kri-; •G <br />N' Z< ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />�•.. _ �P <br />Telephone: (209)468-3420 Fax: (209) 468-3433 Web: www.siaov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION <br />ION REPORT <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ Caldwell System ❑ Other <br />❑ electronic Serial #: <br />Spill bucket ❑ minimum 5 gallon <br />❑ line test programmed <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Primary piping testing at: <br />❑ electronic Serial #: <br />psi <br />❑ line test programmed <br />minutes <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />UDC(s) Piping <br />❑ fail safe Serial #: <br />Sump(s) UST(s) <br />❑ NA <br />Testing for the above components are next due by: <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />Cold start of monitoring panel <br />❑ fail safe Serial #: <br />Corrosion protection <br />❑ NA <br />Other: see below <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />16 This UST facility is APPROVED to operate <br />❑ This UST facility is NOT APPROVED to operate <br />THIS F CILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD l p ctor: Received By: Title ' <br />EHD <br />D23e I/Cj 21 <br />UST SERVICE REQUEST INSPECTION REPORT <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 21 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />THIS F CILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD l p ctor: Received By: Title ' <br />EHD <br />D23e I/Cj 21 <br />UST SERVICE REQUEST INSPECTION REPORT <br />