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OP.QuIN C <br /> SAN JOAQUIN COUNTY <br /> WNVIRONMENTAL HEALTH DEPARTMENT <br /> :. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 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: Inspe tion Date: <br /> Facility Address: Service equest#. <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: _/ 7 Spill bucket j minimum 5 gallon <br /> F1 ❑ electronic Serial#: ® 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other 00-k / <br /> Leak detector l <br /> ❑ mechanical Model: Spill bucket minimum-,5 gallon <br /> F-1 <br /> ❑ electronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor 671-1 <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ ❑ fail safe Serial#: ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: <br /> C(s) Piping <br /> El fail safe Serial#: SuDmp(s) o S LIST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> El positive shutdown Model: x)11q <br /> El fail safe Serial#: <br /> El NA Note: Please be aware that 20 containment components are required to be tested upon <br /> 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 /> l_ This UST facility is APPROVED ❑ This UST facility is NOT APPROVED to operate <br /> a4- <br /> II Y63zX t✓ <br /> Tu11--- wa 5 JA0(&QaA <br /> TO"ACILITY IS SU JECT TO REINSPECTON AT ANY TI A EH 'S CURRENT HOURLY RATE. I <br /> EHD pe r: eived Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />