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�Qurh SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Fa 'I' y Na e: Ins ection Date: Faci it Address: Service Request #: ite service Te nician's Name: ICC ervice Techni 'an/ nstaller Exp. Date: Manufacturer Training: S RVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ mechanical Model: Serial # ❑ electronic ❑ ❑ line test pro ramme sensor ea ❑ positive shutdown Model ❑ fail safe Serial #: ❑ NA ❑ L seI sol' I � " I�� El positive shutdown Model: - ❑ fail safe Serial #: k ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% Overfill prevention (see LG letter 150-1) ❑ This UST facility is APPROVED to operate (H SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) USTI ❑ Testing for the above components are next due by: Note: Please be aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection Other: see below ❑ This UST facility is NOT APPROVED to operate I 90 THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOLIREY RATE. Received By: Title: EHynsp r , �, UST SERVICE REQUEST INSPECTION REPOR EHD 23-04