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4ufW <br /> SAN JOAQUIN COUNTY <br /> ¢{ _y ENVIRONMENTAL HEALTH DEPARTMEN*ao <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> • �9[IFORa\� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> j —/ 7— /3 <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Servic=chnicianlinstaller Exp.Date: Manufacturer Training: <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: El _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 /> ❑ fail safe Serial#: Note: Please be aware that 20 containment components are required to is 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 /> 1:1 Overfill prevention (see LG letter 150-1) Other: see below <br /> ❑ This UST facility is APPROVED to operate This LIST facility is NOT APPROVED to operate <br /> I`I(ii, J--�4 7 h +n 1I 27 G'YI Gvt lJ�( 'r <br /> T I l)y h \ ) 1 5 <br /> 'c-0a <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I F Received By: / Title: <br /> / loci <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130/12 <br />