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�,• .E' .o SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />'. <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.saov.or /p ehd <br />4�,;i-6 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Insp tion Date: <br />Fad 't dress: Ser ice R uesk #: <br />CIAOn tte Service Tec nician's Name: IC Service Technl lanllnstaller Exp. Date: a ufacturer T aining: if <br />This UST facility is APPROVED to operate <br />IFI <br />SERVICE <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ mechanical Model: <br />❑ Caldwell System El Other <br />❑ electronic Serial #: <br />Spill bucket Elminimum 5 gallon <br />❑ line test programmed <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Leak detector <br />❑ Caldwell System O Other <br />❑ mechanical Model: <br />Primary piping testing at: <br />❑ electronic Serial #: <br />psi <br />❑ line test prog rammed <br />minutes <br />sensor <br />0 <br />❑ positive shutdown Model: <br />UDC(s) Piping <br />❑ fail safe Serial #: <br />Sump(s) UST(s) <br />❑ NA <br />Testing for the above components are next due by: <br />sensor <br />Note: Please be aware that 2' containment components are required to be tested upon <br />Installation, 6 months after, and every 36 months thereafter. <br />❑ positive shutdown Model: <br />Cold start of monitoring panel <br />❑ fail safe Serial #: <br />Corrosion protection <br />❑ NA <br />Other: see below <br />sensor <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />® <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />This UST facility is APPROVED to operate <br />IFI <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />© <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System El Other <br />Spill bucket Elminimum 5 gallon <br />El <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System O Other <br />Primary piping testing at: <br />Q <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Testing for the above components are next due by: <br />Note: Please be aware that 2' containment components are required to be tested upon <br />Installation, 6 months after, and every 36 months thereafter. <br />Cold start of monitoring panel <br />Corrosion protection <br />Other: see below <br />l7 This LIST facility is NOT APPROVED to operate <br />IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Received By Title: <br />UST SERVICE REQUEST INSPECTION REPORT <br />EHQ 23-04 <br />Rev 4/30/12 <br />