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o.F4u'lN`.c .. <br /> ?:T •p� SAN JOAQUIN COUNTY <br /> t►ENVIRONMENTAL HEALTH DEPARTMENT/ <br /> N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> . p. 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 /> . 5' l.` s �1- fq, /3 <br /> Facility Address: I Service Request*: <br /> Onsite Service Technician's Name: ICC Service T chnicianllnstaller Exp.Date: Manufacturer Training: <br /> Jc <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 /> ❑ ELmechanical Model: ❑ ❑ I 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#: Surl 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 Y containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every W 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 /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> sT <br /> t <br /> S F CILIT SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EH sp t Rece'ved By: — � Title: <br /> E b UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130jo <br />