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AQU Ily. <br />�o..e®G SAN JOAQUIN COUNTY <br />WNVIRONMENTAL HEALTH DEPARTMEN16 <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />x = Telephone: (209) 46$-3420 Fax: (209) 468-3433 Web: www.sigov.orgleh4 <br />��lko�a <br />UNDERGROUND STORAGE TANK( (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Facility Address: <br />Qnsite Service Technician's Name: ICC <br />ce Technicianlinstaller Exp. Date: <br />SERVICE <br />❑ <br />❑ rr <br />'j <br />F1 <br />❑ IT <br />❑ <br />if,-Yv <br />17 <br />Spill bucket ❑ minimum 5 gallo <br />C <br />❑P( <br />❑ <br />❑ fa <br />❑ N. <br />❑ PC <br />❑ <br />psi <br />❑ fa <br />minutes <br />❑ N, <br />;. <br />E) pc <br />© <br />❑ fa <br />❑ Ni <br />i k, � 11 at 95% <br />Drop tube with mechanical u.... at 95% <br />❑ <br />Testing for the above components are next due by: <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />s This UST facility is APPROVED to operate <br />C <br />THIS FACILITY IS SUBJECT TO REINSPEI <br />EHD InstiectoG 1Rece <br />EHD <br />Rev• <br />Date: <br />/ —! <br />Service Request #: <br />�1--D-0t' ( -7 Z' <br />Manufacturer Training: <br />o AJ `tl(l <br />SERVICEy <br />r <br />C�L Spill bucket minimum 5 gallon <br />'j <br />❑ 1 hour hydrostatic ❑ Incon T5 -STS <br />❑ Caldwell System --45bOther <br />if,-Yv <br />Spill bucket ❑ minimum 5 gallo <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />Ll <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) LIST(s) <br />❑ <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 />❑ <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 />3 <br />NY TIME AT EHD'S CURRENT HOURLY RATE. <br />UST SERVICE REQUEST INSPECTION REPORT <br />