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OAau I <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL 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 /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: [CC Service Technician/installer Exp.Date: Manufacturer Training: <br /> br7m RD-kb N(A/� VD, 0V'\+; \0 1-2\/23 <br /> .SERVICE SERVICE <br /> Leak detector Spill bucket -�9'minimurn 5 gallon <br /> ❑ 0 mechanical Model: T9,\1 hour hydrostatic El)ncon TS-STS <br /> 0 electronic Serial: <br /> 0 line test 0 Caldwell System 0 Other <br /> p rogrammed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> 171 0 mechanical Model: F-1 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial 0 Caldwell System 11 Other <br /> 0 line test programmed <br /> sensor Primary piping testing at: <br /> 1:1 0 positive shutdown Model: El —psi <br /> 0 fail safe Serial minutes <br /> 0 NA <br /> sensor Secondary containment testing for: <br /> El 0 positive shutdown Model: UDC(s) Piping <br /> El fail safe Serial #: Sump(s) UST(s) <br /> 0 NA sensor ❑ Testing for the above components are next due by: <br /> El El positive shutdown Model: <br /> 0 fail safe Serial #: Note: Please be aware that 2'containment components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> El — Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> El — Drop tube with mechanical overfill at 95% El Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) El Other: see below <br /> XThis UST facility is APPROVED to operate El This UST facility is NOT APPROVED to operate <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S-CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: rj <br /> Ic <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />