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Pqutry <br />SAN JOAQUIN COUNTY <br />N�{ <br />&NVIRONMENTAL HEALTH DEPARTMEN <br />4 <br />�W 1868 East Hazelton Avenue, Stockton, CA 95205'232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />iFoR��P <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />w/ <br />❑ mechanical Model: <br />Facility Address: <br />Service Request #: <br />❑ <br />r <br />Onsite Service Technician's Name:ICC <br />Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />��,� c -ie-. �,.�r9 <br />�� >1 <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />EHD Inspector. <br />❑ fail safe Serial #: <br />R eived By: -_ " r <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <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 />❑ This UST facility is APPROVED to operate <br />SERVICE <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 />EHD Inspector. <br />UDC(s) Piping <br />R eived By: -_ " r <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 2° containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 f r� UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />r <br />THIS FACILITY IS SUBJECT TO REINSPECTM AT ANY TIME AT EHD'S C ENT HOURLY RATE. <br />EHD Inspector. <br />R eived By: -_ " r <br />Title: <br />/ <br />EHD 23-04 f r� UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />