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D <br /> SAN JOAQUIN COUNTY '-,1ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <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 /> Facil' Name: Ins action Dat <br /> �` ► ( 3 ` -1 <br /> Facility Address: Sam' a Request#: <br /> b�f <br /> Onsite Service T chnician's aa: ICC Service T chnician/Installer Exp.Date: Manufacturer Training: <br /> S /� <br /> SERVICE SERVICE <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 /> 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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ _psi <br /> ❑ fall safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Sump(s) UST(S) <br /> ❑ NAE] <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> '❑fail safe Serial#: <br /> Note Please be aware thatYco containment components are requiretl to be tested upon <br /> ❑ NA installation,6 months after,a ci every 36 months thereafter. <br /> ❑ _Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> Q _Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) )KrOther: see below ug'IN40. <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> UL L- UL <br /> 4341 . roe r�) '( .N. L�(( <br /> 8� d <br /> MFACILTY <br /> it <br /> U C viEINSPECTION AT TIME AT D'S CURRENT HOURLY RATE. <br /> EHD Inspedo Received By: - Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />