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oG, SAN JOAQUIN COUNTY <br /> Q' ENVIRONMENTAL HEALTH DEPARTMENT <br /> he 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone.(209) 468-3420 s=ax.(209) 468-3433Web:www.sigov.org/ehd <br /> STORAGEUNDERGROUND T (UST) PROGRAM SERVICE REQUEST INSPECTION <br /> Facility Name: Inspection Data: <br /> 1A W,2 <br /> 7//0 <br /> ! <br /> Facility Address: / Service Request#: <br /> ►0 E <br /> Onsite Service Technician's Name: IC Service-technician/installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> El electronic Serial: El El hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ® El❑ electronic Serial #: ❑ 1 hour hydrostatic ElIncon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> sensor <br /> ❑ <br /> 11 positive shutdown Model: Primary psi <br /> piping testing at: <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <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 /> ❑ fall 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 belowSoil Sam dl to I <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> I1- I <br /> G -Ca <br /> THIS FACILITY IS SUBJECT TO REINSPECTION ATA Y TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: tv Titl <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />