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O.Pau IN•.0 <br /> �� °2 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Ni 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 1 .P Telephone:(209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> `fid �. �'1�; �dck�-vr� S <br /> Onsite Service Technician's Name: ICC Service Technicia-dAnstaller Exp.Date: Manufacturer Training: <br /> Uh <br /> SERVICE SERVICE <br /> Leak detector <br /> [I mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial: ❑ El hour hydrostatic 11 Incon TS-STS <br /> El line test programmed <br /> El Caldwell System 1-1 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 El Ll shutdown Model: Primary piping testing at: <br /> si <br /> El fail safe Serial #: _ p <br /> minutes <br /> El NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ 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 /> ❑ ❑ 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 APPROVED to operate <br /> �, it✓✓ L' S4 <br /> THIS FACILITY IS SUBJECT tO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EH spe o . ceived By: <br /> � <br /> EHD 4 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4 0/12 <br />