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SAN JOAQUIN COUNTY <br /> 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 /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> L ( <5 <br /> Facility Ad' ss:\ Service Request#: <br /> 1 }Ine vo <br /> Onsite Service Technician's Na e: Icc ce Technician/Instal ler xp.Date: Manufacturer Training: <br /> t°►'t n e - <br /> SERVICE SERVICE <br /> Leak detector <br /> ISpill bucket El minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical Model pill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: '10 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ El psi <br /> ❑ fail safe Serial#: <br /> ❑ NA minutes <br /> sensor Sec ndary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(S) UST(s) <br /> ❑ NA <br /> sensor T sting for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: 5 F �`1S Q.- <br /> ❑ fail safe Serial#: Note Please be aware that 21 containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> Z Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> 3 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 Thi UST facility is NOT APPROVED to era e <br /> WK 11 4A <br /> y) p r <br /> _ a �r, <br /> C,0 wl V <br /> d �—_ <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector Received Title: <br /> V`V is le <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />