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oPqulty o SAN JOAQUIN COUNTY <br /> ~`ENVIRONMENTAL HEALTH DEPARTMEN'tep4 <br /> ¢: a <br /> ` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> !+, <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> ..o'9t jF OR�`p <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> `€F `$' S- zit- /3 <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Se ice Technicianllnstaller Exp.Date: Manufacturer Training: <br /> 3000 -7/210 <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 /> El EJ mechanical Model: EJ El El hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#:❑ line test programmed ElCaldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El —psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: }- <br /> ❑ ❑ positive shutdown Model: UDC(s) 5 St Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA -kh <br /> sensor Testing for the above components are ne due by: <br /> ❑ ❑ positive shutdown Model: �l�f�//{• <br /> El <br /> Serial Serial#: Noe: Please be av{are that 2'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) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate X This UST facility is NOT APPROVED to operate <br /> JA rl <br /> XkDy'. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: By; Tle. <br /> v <br /> Tk <br /> SA <br /> 'L7 <br /> Rev 4130/12 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br />