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o•¢4u�'kL' - SAN JOAQUIN COUNTY <br /> 'y <br /> q� � *,.CNVIRONMENTALHERLTH DEPARTMENT�d <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.siclov.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 Nam/e1: ICC Se echnician/Installer Exp.Date: Manufacturer Training: <br /> JhrasY�zic- �'l5 -J i I� 2 2 1 <br /> in r <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: H,— <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fad safe Serial#: Sump(s) 6 a �tLIST(s) <br /> ❑ NA sensor Testing for the above com ne is are nextydue lb L <br /> ❑ ❑ positive shutdown Model: �) , 7j I— <br /> ❑ fail safe Serial#: Note' Please aware the 2 containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S C RENT HOURLY RATE. <br /> EHD Inspe R ived B : Title: <br /> Ong <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />