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/o.�:�.c G SAN JOA©UIN COUNTY <br />��� � �"? ENVIRONMENTAL HEALTH DEPARTMENT <br />��` 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />. <br />�'�. ",;�/ Telephone: (209} 468-3420 Fax: (209) 468-3433 Web: www.slgov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION R;=Pi�RT <br />SERVICE <br />Leak detector <br />❑ ❑mechanical Model: <br />❑ electronic Serial #: <br />❑ line test ro rammed <br />Leak detector <br />❑ ❑mechanical Model: <br />❑ electronic Serial #.: <br />❑ line test ro rammed <br />sensor <br />❑ ❑positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />I sensor <br />❑ ❑positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ ❑positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ Drop tube with mechanical overfill at 95% <br />❑ Drop tube with mechanical overfill at 95% <br />❑ Overfill prevention (see LG letter 150-1) <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑Incon TS -STS <br />❑Caldwell System ❑Other <br />Spill bucket ❑minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑Incon TS -STS <br />❑ Caldwell System ❑Other <br />Primary piping testing at: <br />❑ psi <br />minutes <br />Secondary containment testing for: <br />UDC(s} <br />Sumps) <br />Piping <br />UST(s) <br />❑ I Testing for the above components are next due by: <br />Note: Please be aware that 2° containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ � Cold start of monitoring panel <br />❑ � Corrosion protection <br />Other: see below <br />This UST facility is NOT APPROVED to operate <br />til 1 <br />r �!'� Nn � t � fi <br />_ s�e�. <br />� <br />a ; � � �. rv�taer�t <br />� N� ES � �. <br />THIS FACILITY IS SUBJECT TO REINSPECTION T ANY IME AT <br />EHD'S CURB NT HOURL RATE. <br />EHD Inspector• <br />''�P� rx <br />Received <br />� rc�-�-� <br />Title: , <br />�� �-�L-� t � � �'t �n <br />�� <br />EHD 23-04 , UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />