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O.P�U IN••.0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N`• ':, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c. P Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> /FORS; <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit Name: Inspection Date: <br /> i <br /> Fa^lily Address Service Request# '� <br /> Onsite Service T nician' Name ICC Se vice Technician/installer Exp.Date: Manufacturer Training: <br /> -�7 1-Z- 1 <br /> SERVICE SERVICE <br /> Leak detector 'Spill bucket minimum 5 gallon <br /> ❑ <br /> 1:1 mechanical Model: 1 hour hydrostatic ❑ Incon TS-STS <br /> 1:1 electronic Serial #: Caldwell System 11 Other <br /> El 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 /> F-1ElElpositive shutdown Model: p <br /> si <br /> Elfail safe Serial #: minutes <br /> ❑ NA <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 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%t ❑ Corrosion protection <br /> Overfill prevention (see LG letter 150-1) X1d' ' ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Lt <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: 'e / <br /> Received : Title: <br /> EHD 23-04 Ll UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />