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Ot4Uit C <br /> SAN JOAQUIN COUNTY <br /> wENVIRONMENTAL HEALTH DEPARTMEN ISI� <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> P. Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 9ttFORa` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Fa Ity A dres g � I t '. <br /> 3� I <br /> 0?!%'e Service Technician'sName: ICC Service Te nicianlinstaller Exp.Date: Manufacturer Training: <br /> "I T- <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ ❑ mechanical Madel: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> El El mechanical Model:❑ electronic Serial#: El El1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El _ si <br /> ❑ fall safe Serial#: p <br /> ❑ 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 20 oontainment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 menths 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 �Nie"US 48eRlty is NOT APPROVED to operate <br /> 4n mwwoxv COW-i PA WV ki 19;A0, <br /> r. <br /> Ar - NVYIP� fill <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD or: Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 <br />