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OPQu{Y•.0 <br /> .o` I SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y'.1111a j <br /> .. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �.. P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s'gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: <br /> Inspection Date: <br /> Facility Address: <br /> ! , J � Service Request#: <br /> Onsite Service Technician's Name: I C Service Technician/Installer xp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector n (� <br /> mechanical Model: V t" LLD Spill bucket ❑ minimum 5 gallon <br /> electronic Serial #: ❑ LCCaldwell <br /> ur hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed System ❑ Other <br /> Leak detector <br /> ❑ ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> El ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ fail safe Serial #: ❑ psi <br /> ❑ NA minutes <br /> sensor JEIT..fin <br /> econdary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC s <br /> ❑ fail safe Serial #; ( ) Piping <br /> ❑ NA Sump(s) UST(s) <br /> sensorg for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: <br /> ❑ NA Ncte; Please 6e aware that 2°containment components are required to he tested upon <br /> installation,6 months atter,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> Loo . <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 /> V-6, <br /> THIS FACILITY 1S SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD In ctor: Re ived B <br /> Title: <br /> EHD23-04a / <br /> Rev 4130/12 UST SERVIer:REQUEST INSPECTION REPORT <br />