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''—•+E_''t 'O SAN JOAQUIN COUNTY <br /> c to—IC 'a<l ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3x20 Fax:(209) 468-3433 Web:www.sipov.org/ehd <br /> 4�%Fo.4tN, <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> MOA - l <br /> Facility Address: Service Request#: <br /> Fso n A� <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <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 /> 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 <br /> El shutdown Model: Primary piping testing at: <br /> ❑ <br /> El fail safe Serial #: ❑ psi <br /> El 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 This ST facility is NOT APPROVED to operate <br /> Uk 1(;011' <br /> T o e_ <br /> e� n <br /> �rT Q <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIM AT EHD'S CURRENT HOURLY RATE. <br /> =HD Inspector: Receive Title: <br /> 1 Ail\U0r <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />