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0 q uiy�\ <br /> ' ' ° SAN JOAQUIN COUNTY <br /> !e ENVIRONMENTAL HEALTH DEPARTMENT <br /> j ! 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 <br /> 11 ' % Telephone: ( 209 ) 468 - 3420 Fax: ( 209 ) 46& 3433 Webo www . sigov . org/ehd <br /> '�1PORi,� <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> 06 <br /> Facility Address : _ Service Request # : <br /> Onsite Service Technician ' s Name : ICC Service Technician/Installer Exp . Date : Manufacturer Training : <br /> Mp4k TY1 6 A P� 666P :� Pf M P L r� � <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model : Spill bucket ❑ minimum 5 gallon <br /> F] El El❑ electronic Serial # : 1 hour hydrostatic ElIncon TS - STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model : ❑ ❑ 1 hour hydrostatic ❑ Incon TS - STS <br /> ❑ electronic Serial # : ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> ❑ <br /> El shutdown Model : El psi piping testing at : <br /> El fail safe Serial # : p <br /> minutes <br /> El 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 /> ❑ 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 /> ❑ Overfill prevention ( see LG letter 150- 1 ) [ Other: see below <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> { �^ <br /> � i G" �ls, % h , tC �w 07 <br /> . r <br /> t9J 6V � I � <br /> c \ t <br /> U All <br /> k4l <br /> / <br /> HIS FACILITY SILIBJECT TO REINSPECTION AT ANY TWAE AT EHD ' S CURRENT HOURLY RATE . <br /> LEHD Inspector: Re iv y: Title : <br /> n <br /> EHD 23-04 1 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 Pct I <br />