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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: SERVICE SERVICE Inspection Date: uigtecapill t ❑ 5-[ ► �i Facility Address: mechanical Model: Service Request #: Onsite Service Technician's Name: electronic ICC Service Technician/Installer Expiate: Manufacturer Training: Cs r r y 0 I c� ❑ Caldwell System ❑ Other Leak detector ❑ ❑ ❑ This UST facility is APPROVED to operate SERVICE SERVICE Spill bucket ❑ minimum Leak detector ❑ ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ line test programmed ❑ Caldwell System ❑ Other Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: Secondary containment testing for: ❑ line test programmed UDC(s) sensor ❑ ❑ positive shutdown Model: next due by: ❑ fail safe Serial #: i ❑ NA ❑ Cold start of monitoring panel THIS FACILITY IS sensor Corrosion protection ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes dALM M11" Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: y • + �� 1 Note: Please be aware that 20 containment components are required to be tested upon i installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel THIS FACILITY IS ❑ Corrosion protection RATE, Other: see below This UST facility is NOT APPROVED to operate EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT WARLIai 4P MIN 71101 WOME W! W1 dALM M11" ArAil y • + �� 1 I i THIS FACILITY IS SUBJECT TO REINSPECTION• RATE, EHD Inspector, Received B EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT