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oP4�IN• o <br /> ?:' Ej''••po SAN JOAQUIN COUNTY <br /> Nc• � NVIRONMENTAL HEALTH DEPARTMEN <br /> ` Ast Hazelton Avenue, Stockton, CA 952 Iz32 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.siciov.org/ehd <br /> �dYlkoR��P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Insp;ction Date: <br /> (J�1} p <br /> Facili ddress: Service Request#: <br /> _ <br /> Onsi Service Technician' Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer raining: <br /> V I <br /> SERVICE SERVICE <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> El ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> El El electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ _psi <br /> ❑ fall safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> El ❑ 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 /> ElElpositive shutdown Model: <br /> ❑ fall safe Serial#: Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA nstallation,6 months after,and every 36 months 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) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> i-144. OCK 6M U c <br /> r✓. MIA (� <br /> r h(� r <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD 1 r: Receive Title: <br /> EHD 23-04 UST SERVICE 4QUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />