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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si-ov.org/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: Inspection Date: <br />Facility Address: Service Request #: <br />Onsite Service Technician's Name: ICC Service Technician/Installer Exo. Date: Manufacturer Training: <br />❑ This UST facility is APPROVED to operate <br />SERVICE <br />SERVICE <br />Spill bucket ❑ minimum <br />Leak detector <br />❑ <br />❑ <br />mechanical Model: <br />TO] i► , , <br />❑ <br />electronic Serial #: <br />Spill bucket ❑ minimum <br />❑ line test programmed <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Leak detector <br />F111mechanical <br />❑ Caldwell System ❑ Other <br />Model: <br />❑ <br />electronic Serial #: <br />❑ <br />psi <br />❑ line test programmed <br />10 <br />minutes <br />sensor <br />❑ <br />❑ <br />positive shutdown Model: <br />❑ <br />fail safe Serial #: <br />❑ <br />NA <br />❑ <br />Testing for the above components are <br />sensor <br />❑ <br />❑ <br />positive shutdown Model: <br />❑ <br />fail safe Serial #: <br />❑ <br />❑ <br />NA <br />❑ <br />Corrosion protection <br />sensor <br />❑ <br />❑ <br />positive shutdown Model: <br />❑ <br />fail safe Serial #: <br />❑ <br />NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />❑ This UST facility is APPROVED to operate <br />This UST facility is NOT APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum <br />5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />W' OFM <br />TO] i► , , <br />❑ Caldwell System ❑ Other <br />Allj <br />Spill bucket ❑ minimum <br />5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />M.111MRA <br />10 <br />minutes <br />Secondary containment testing for: <br />rA <br />UDC(s) <br />Piping <br />Sump(s) <br />UST(s) <br />❑ <br />Testing for the above components are <br />next due by: <br />Note: Please be aware that 20 containment components are required <br />to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below <br />This UST facility is NOT APPROVED to operate <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />W' OFM <br />TO] i► , , <br />�- , <br />Allj <br />W, in l <br />M.111MRA <br />10 <br />rA <br />THIS FACILITY IS <br />SUBJECT TO REINSPECTION AT ANY <br />TIME AT EHD'S CURRENT HOURLY <br />EHD Inspector• <br />vop <br />EHD 23-04 <br />Rev 4/30/12 <br />UST SERVICE REQUEST INSPECTION REPORT <br />