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oNo.ulN O <br /> 0 SAN JOAQUIN COUNTY <br /> y: ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> �fFORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> ���•fes �� �� <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's N' ICC Ser ice Technician/Installer Exp.Date: Manufa turer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ,<mechanical Model: RM LDV2000 Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #:=-F5 I Zia ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> El El❑ electronic Serial #: El hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> El El positive shutdown Model: El psi piping testing at: <br /> ❑fail safe Serial #: p <br /> El NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(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 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 /> El Overfill prevention (see LG letter 150-1) 01 Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> MtL - f <br /> d-' , <br /> THIS FACILR IS SUBJECT TO REINSPECTION AT ANY TIME AT HD'S CURRENT HOURLY RATE. <br /> EHD Ins ector: - Received Title: — <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />