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a!'au'jV • SAN JOAQUIN COUNTY 19 <br /> :._T77, <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sugov.org/ehd <br /> �{IFC4t•� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date:!bc // <br /> 7 O <br /> Facility Address: Service Req est#: <br /> oma; � 15 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. ate: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> 1:1 fail safe Serial#: <br /> 1:1 NA minutes <br /> sensor S con ary c ntainment testing for: <br /> ElElpositive shutdown Model: } h XXDC(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 /> ❑ 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) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> R' <br /> vM• <br /> =€ill CA <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT NY TIME AT EHD'S CU RENT HOURLY RATE. <br /> EHD Inspecto : Received B Title: <br /> 23-04 <br /> Rev 4!30/10/12 UST S RVICE REQUEST INSP CTION REPORT <br /> Rev <br />