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OAQU IN••.0 ?�, o SAN JOAQUIN COUNTY OIQ: a ENVIRONMENTAL HEALTH DEPARTME N ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd ORN` ❑ UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: Facility Addres'15, Service Request #: Onsite Service Thni i'an's Name: ICC Sery1ce Technician/Installer Exp. Date: Man ufactu're/r {raining: ❑ line test programmed ❑ SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed sensor ci t� ❑ positive shutdown Model:. - (� ❑ fail safe Serial #: ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) This UST facility is APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below THIS FACILITY IS SUBJECT TO REINSPECTION AT D Inspector: EHD 23-04 Rev 4/30/12 ❑ This UST facility is NOT APPROVED to operate ME AT EHD'S CURRENT HOURLY RATE. Title: UST SERVICE REQUEST INSPECTION REPORT