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SAN JOAQUIN COUNTY <br />ONVIRONMENTAL HEALTH DEPARTMENT <br />` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />-. <br />'Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s ov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facil <br />Facility <br />Onsite Service Technician's Name <br />IGC Service Technicianlinstaller Exp. Date: <br />I'VI -7114 <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />minutes <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <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 />Inspection Date: <br />Service Request #: <br />712�o6E66 <br />cturer Training: <br />4A 15 <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />jLj--1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <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 />A/ 14 <br />Note: Please be aware that 21 containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />�: <br />THIS AUILI SUBJECT TO REINSPECT AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Insoe r:/7 / I Rece Title: <br />EHD 23-6� V v r r v l % UST SERVICE REQUEST INSPECTION REPORT <br />Rev 41d // l / <br />