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oAqury.•.0 <br /> SAN JOAQUIN COUNTY <br /> �, NVIRONMENTAL 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 /> �IFOFN� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> F�i ility Name: ^ , , � Inspection Date: <br /> Facility Address: Service Request#: <br /> f-, (>`ftll <br /> Onsite Service Technician's ame: ICC 5r rvice Technician/Installer Exp.Date: Manufacturer Training: <br /> uv <br /> SERVI SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> Ll ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> _Leak detector _Spill bucket El minimum 5 gallon <br /> E3 ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: <br /> e test programmed ❑ Caldwell System ❑ Other <br /> ❑ lin <br /> sensor <br /> utdown Model: Primary piping testing at: <br /> ❑ ❑ positive sh ❑ _ <br /> ❑ fall safe Serial#: psiminutes <br /> ❑ NA — <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Nesting for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: Note: Please be aware that 20 containment components are requiretl to be tested upon <br /> ❑ NA rate aeon,6 months after,and every 36 months thereeftar. <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 /> cjIL IN <br /> WN <br /> THIS Ffl"TAWNSUBAECTT REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received Byj Title: <br /> EHD 23-04 V UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />