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4UI,y c <br /> SAN JOAQUIN COUNTY <br /> ..rENVIRONMENTAL HEALTH DEPARTMENI%4. <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> v P Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> 9�I F O•R�h <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Narge: Inspection Date: <br /> I <br /> Facility Addres Service Request / <br /> On Service ethnic' n's Narne, ]CC Service ec nicianllnstaller Exp.Date: Manufacturer Training: S <br /> SERVICE SERVICE <br /> eak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket Elminimum 5 gallon <br /> _ <br /> ❑ ❑ mechanical Model: El ❑ 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 /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: Note. Please be aware that P containment cornponents are required to be tested upon <br /> ❑ NA installation,6 months atter,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 /> 9 )b%-L <br /> ❑ This UST facility is APPROVED to operate This^UST ! is NOT APPROVED to operate <br /> i 1�t 1�rJLPW oN <br /> lie. <br /> THIS LITY IS SUBJECT TO EINSPECT ON AT ANT TIM AT EHD'S CURRENT HOURLY RATE. <br /> Title::k <br /> EHD Inspector 2 � � bed � <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION EPORT <br /> Rev 4/30/12 <br />