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oPQutN c �, SAN JOAQUIN COUNTY <br /> c: ENVIRONMENTAL HEALTH DEPARTMENT <br /> W < <br /> ,k 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sioov.org/ehd <br /> OR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspect'on Dat <br /> Facility Address: j,,,, Service Request <br /> Onsite Se vice Te nician's Name: ICC Service Technician/Installer Exp.Date: ManuaGtuure Training: <br /> `v( " 2 Z <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial:: ElEl1 hour hydrostatic ElIncon TS-STS <br /> 11 line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> El positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor Seco ary C ntainment testing for: 9U V d�a <br /> ❑ ❑ positive shutdown Model: 4 UDC(s)I� �" d Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) T <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑fail safe Serial #: Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA installation,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 APPROV to operate <br /> Q lv <br /> \/4-u <br /> ot ' <br /> Ab <br /> r <br /> vkcr)k <br /> n n <br /> >r O W <br /> A a <br /> Zr-r <br /> THISr FACILITY IS SUBJECT TO PlEINSPECTION A Y TIM4 AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />