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SAN JOAQUIN COUNTY <br /> c' + ENVIRONMENTAL HEALTH DEPARTMENT <br /> w. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 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: Inspection Date: <br /> Faciiity Address: Service Request#: _ <br /> 3 5 <br /> Onsite Service Technician's Name: ICC Serviceechnicia staller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <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 /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El 1 hour hydrostatic L1Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> El <br /> El fail safe Serial #: ❑ minutes <br /> ❑ 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 #: <br /> 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 LIS letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> ,� ►r` z° `r <br /> o h <br /> vLn ( k <br /> cl U V; lu 2 ( �S N1 S <br /> THIS FACILITY IS SUBJECT TO REINSPECTI NAT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD s ector- r Recei y: Titlee <br /> EHD 23 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/ 2 <br />