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oAqu�N.c <br /> 4' 'E''OG SAN .JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEI\. <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> ��fFORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fa ility Name: Inspection Date: <br /> C�r <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Trainin 1-V,," , <br /> VC <br /> SERVICE SERVICE <br /> Leak detector y il <br /> Spill bucket�� -' H minimum 5 gallon <br /> F-1 ❑ mechanical Model: hour hydrostatic ElIncon TS-STS <br /> El electronic Serial #. El Caldwell System [I Other <br /> 111 line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket [I minimum 5 gallon <br /> F-1 ❑ electronic Serial: El El hour hydrostatic 11Inoon TS-STS <br /> ❑ line test programmed [-1 Caldwell System [I Other <br /> sensor <br /> F-1 El shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> Ll 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 21 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 El This UST facility is NOT APPROVED to operate <br /> This <br /> "likk 97 dol <br /> kw Al A-eg'I djo X40-- W<- �t� 544vlc� 4 6-1-0 4 ►� <br /> 4 <br /> 14 5 mtl caN2� alill ikI.f <br /> TI 61toic •, <br /> v <br /> THIS FA IL iY- ECT�TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: i ! eiv y: Title: <br /> i <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />