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Pqu1•ry•.c <br /> SAN JOAQUIN COUNTY <br /> m %w ENVIRONMENTAL HEALTH DEPARTMEN+/ <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.siaov.org/ehd <br /> �4<f FORa`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> &Si <br /> Facility Name: Inspection Date: <br /> p -243 Address: Service Request#: <br /> �-/ <br /> Onsite Service Technician's Name: ICC Service Te c1hn'ician/lnstaller Exp.Date: Manufacturer Trai tpg: Li <br /> �t <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 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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fall safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> El ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: Note: Please be aware that 7 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) ❑ I Other: see below <br /> ❑ This UST facility is APPROVED to operate ST•#lecfttty is NOT APPROVED to operate <br /> S <br /> US �- <br /> s <br /> THIS FAC LITY IS SUBJECT TO REIRSPECTICIN AT ANY TIM EHD'S CURRENT HOURLY RATE. <br /> EHD In Received B : ,w Title: <br /> EHD 23-64 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4136112 <br />