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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />X <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />" Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.org/ehd <br />�9L / F O R��P �_ <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Leak detector <br />Inspection Date; <br />/ t <br />tJ�J <br />❑ mechanical Model: <br />,f. <br />Facility Address: <br />lwell System <br />Service R "nest <br />Spill bucket <br />❑ line test. ro rammed <br />Onsite Service Technician's Name: <br />ICC eryice Technics nstaller Exp. Date: <br />Manufacturer Training: <br />1well System <br />Q mechanical Model: <br />fiill rpreventlon {see LC ietter.150 1) Othe <br />UST *10ty es'A i 41iED:to ope `aie 'his <br />z <br />....inx t i.,.ga <br />EHD 23.04' <br />Rev 4/30/12 <br />SERVICE <br />Leak detector <br />❑ minimum 5 gallon <br />❑ mechanical Model: <br />❑ Incon TS -STS <br />❑ <br />lwell System <br />❑ electronic -Serial #: <br />Spill bucket <br />❑ line test. ro rammed <br />❑ Gi <br />)ur hydrostatic <br />Leek detector` <br />1well System <br />Q mechanical Model: <br />v❑ <br />© <br />❑ electronic Serial #: <br />1 <br />❑line test programmed.: <br />❑ G< <br />sen or . 'Prim <br />dry c ntalnment testing for. <br />positive shutdown Model: <br />El <br />Piping <br />Lhfaii=safe Serial #: <br />= = <br />❑ NA, , <br />sensor;, <br />Secc <br />positive shutdown <<Model: , <br />,fallsafo Serial #: - <br />:�l <br />.._sensor .� <br />Testi <br />® <br />,osl—.0%ve shutdown; Model: <br />4 <br />❑ fall Send #. <br />Note F <br />Ysafe <br />(� <br />Drop tube with mechanical overfill- at 95% <br />Cold <br />L <br />n <br />_ Drop tune wltih mechanical overfill ,at 9% _Coni <br />.; <br />fiill rpreventlon {see LC ietter.150 1) Othe <br />UST *10ty es'A i 41iED:to ope `aie 'his <br />z <br />....inx t i.,.ga <br />EHD 23.04' <br />Rev 4/30/12 <br />SERVICE <br />Spill bucket <br />❑ minimum 5 gallon <br />)ur hydrostatic <br />❑ Incon TS -STS <br />lwell System <br />❑ Other <br />Spill bucket <br />❑ minimum 5 gallon <br />)ur hydrostatic <br />❑ Incon TS -STS <br />1well System <br />i] Other <br />y pii6o testing at: <br />psi <br />mini es <br />dry c ntalnment testing for. <br />UbC(s) " <br />Piping <br />S,urPis)'.. <br />` UST(s) <br />I for the1 above Co.mp oPnentys/a�re next due by: <br />u <br />