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SAN JOAQUIN COUNTY <br /> c i ENVIRONMENTAL HEALTH DEPARTMENT N I <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> . _ Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.siaov.onQ/ehd <br /> 4tiF ORN` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: <br /> S t s Inspection Date: <br /> - <br /> Facility Address: Service Request#: <br /> Oo /J SO-Onsite Service Technician's Name: ICC selvice Technician/Installer Exp.Date: Manufacturer Training: <br /> it rry ?7 /ZJ � I S <br /> �t <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 <br /> ❑ mechanical Model: P gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector _Spill bucket El minimum 5 gallon <br /> ❑ El mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor❑ Primary piping testing at:❑ positive shutdown Model: si <br /> ❑ fad safe Serial#: ��P <br /> ❑ NA 2 minutes -�— 'g-' 45�— <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Sump(s) 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 2° o tainm.nt 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 /> fe <br /> a_ <br /> Tp <br /> q(o j <br /> C), A> be- o� <br /> r <br /> or IG rye Q+' <br /> T A ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I e Re y: Title: <br /> s <br /> EHD 23204 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />