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Agtr i�. <br /> a°:fit�o SAN JOA©UIN COUNTY <br /> <i ENVIRONMENTAL HEALTH DEPARTMENT <br /> ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-•3420 Fax: (209) 468-3433 Web:www.s ov.cr lehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> p <br /> Onsite Service Technician's Name: IGC Service Techni nllnstaller Exp. Date: Manufacturer Training: <br /> � ` tc� — �`r,-kr " n�g <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model. <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> line test programmed <br /> Leak detector <br /> ❑ mechanical Model_ Spill bucket ❑ minimum 5 gallon <br /> mecha <br /> ❑ <br /> ElelectronicSerial #: ❑ LJ1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System LJ Other <br /> sensor <br /> Ll El shutdown Model ❑ Primary piping testing at: <br /> si <br /> f❑ fail safe Serial #: <br /> El NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA ❑ <br /> sensor Testing for the above components are next due by: <br /> ❑ positive shutdown Model: <br /> ❑ ❑ fall safe Serial #: Note. Please be aware that 21 containment components are required to be tested upon <br /> El NA installation.6 months after,and every 36 mcnths 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} IE <br /> Other: see below <br /> El is UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> -4K 1AKk S ( ` �'cvlr; '2 ;Vie C,.�rn ik v, <br /> Svt +.t . V ti ,rvca <br /> THIS FACILITY IS SUBJECT TO REINSPE I© AT AN IME EHD'S CU E T HOURLY R TE. <br /> EHD In ar: R e ed Ti <br /> a c <br /> EHD 23-04 REPORT <br /> Rev 4130/12 <br />