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oAa�I N••.c <br /> ? � .o SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMENT <br /> - <br /> _ 1868 East Hazelton Avenue, Stockton, CA 9520 32 <br /> . P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orq/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> C <br /> Onsite Service Technician's Nam ICC Servic echnt is nstaller Exp.Date: Manufacturer Training: <br /> l2 � Z <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket 11 minimum 5 gallon <br /> E] ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ 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 <br /> El positive shutdown Model: El psi piping testing at: <br /> ❑ fail safe Serial#: p <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ositive shutdown Model: UDC(s) Piping <br /> X 1 ail safe Serial#: Sump(s) UST(s) <br /> ❑ A EJ 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) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> r - O-G-(1 • 7 v• r <br /> yu <br /> THIS FACILITY IS SUBJECT TO REINSPECT" ATWY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rec ' d Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />