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oAq�IN• c <br /> SAN JOAQUIN COUNTY <br /> WNVIRONMENTAL HEALTH DEPARTMENO <br /> �IYE 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> �q�I FOR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: IC ervice Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model >2 ��� ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> )P-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 /> El positive shutdown Model: ElPrimarysiping testing at: <br /> ❑ fail safe Serial#: p <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ positive shutdown Model: UDC <br /> Els( ) 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% Nil 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 /> Gr <br /> THA FACILITY IS SUBJECT TO REINSPECTION T NY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins ctor Rece' ed By: Title: <br /> EHD 23-0 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/1 <br />