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/o.•' ��.ccG SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> u): <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c, 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: 1 Inspecticn D te: p <br /> Facility Address: Service Request#:�� <br /> Onsite Seryjce Technician's me: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> 4/r la,/ <br /> il <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial: ElEl1 hour hydrostatic ElIncon TS-STS <br /> ❑ 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 /> positive shutdown Model: ❑ Primary piping testing at: <br /> El 11 <br /> ❑ 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 #: Note: Please be aware that 2°containment components are required to be tested upon <br /> 1:1 NA ins at 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 Tis UST facl Ity is OT APPROVED to operate <br /> / 6 /t <br /> l Z� <br /> THIS FACILITY IS SUBJECT TO REIN P CTION A NY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp r: eived By: Title: e' <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />