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OR4uIN c SAN JOAQUIN COUNTY <br /> Q. Ne ENVIRONMENTAL HEALTH DEPARTMEN w <br /> m. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> c9G i F O�RN\P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> -7 -!fK,i2-/3 <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> e7:�T-5%i� Lj-j lc , y rs V2 Zol <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket 11 minimum 5 gallon <br /> El El El❑ electronic Serial#: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed E1 Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed <br /> EJ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fall safe Serial#: <br /> El NA minutes <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 /> 171 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 /> ZI 1A1 <br /> H <br /> STP V 2 vg <br /> D— I v P --5V <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I e r: Received B : Title: <br /> EHD 2 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/1 <br />