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PAWN <br /> 'E ' SAN JOAQUIN COUNTY <br /> A ENVIRONMENTAL HEALTH DEPARTMENT <br /> N .e* .640' 0 1868 East Hazelton Avenue , Stockton , CA 95205-6232 <br /> Tele hone: 209 468 - 3420 Fax: 209 468 -3433 Web: www .sigov. orq/ehd <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> ':.�4\ (L (J G If ► G1 <br /> Facility Address: Service Request #: <br /> Onsite Service Technician 's Name : ICC Service Technician/installer Exp, Date: Manufacturer Training : <br /> �lvv � c '1 Gin_- > t Zg Zc ik ( A; 0 C4�; � �, 1 "i ?2? <br /> SERVICE SERVICE <br /> Leak detector p2 Spill bucket D minimum 5 gallon <br /> ❑ ❑ mechanical Model : �i ❑ 1 hour hydrostatic S , Incon T& STS <br /> ❑ electronic Serial # : ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model : ❑ ❑ 1 hour hydrostatic ❑ Incon T& STS <br /> ❑ electronic Serial # : ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at : <br /> ❑ L1positive shutdown Model : Elpsi <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 /> ❑ 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 /> �v This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Ue/4 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD Inspector: Received By: Title : <br /> =< ? C / <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />