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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1+ 1868 East Hazelton Avenue, Stockton, CA 95205-5232 p� Telephone:(209) 488-3424 Fax:(209)458-3433 Web:www.s' ov.or ehd UNDERGROUND STORAGE TANK (LIST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: Facility Address- Service Request#: y Onsite Service Technician's Name: ICC Service Technicianfinstaller Exp.Date: fNanufacturer Training: SERI(ICE SERVICE Leak detector ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon 171IJ❑ electronic Serial #: El hour hydrostatic ElIncon TS-STS 11 line test ro rammed L1 Caldwell System ❑Other Leak detector Spill bucket ❑ minimum 5 gallon ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS ❑ electronic Serial#: ❑ Caldwell System ❑Other ❑ line test programmed sensor ❑ positive shutdown Model: El Primary piping testing at: El tail safe Serial #: psi minutes LJ NA sensor _ Secondary containment testing for: ❑ ❑ positive shutdown Model: UDC(s) Piping ❑ fail safe Serial it: Sump(s) UST(s) ❑ NA sensor ❑ Testing for the above components are next due by: s ❑ ❑ positive shutdown Model: ❑fail safe Serial #: Note: t'Iease be aware ittat 20 containment components are required to be tested upon ❑ NA insiaiiation,6 months after,and every 36 months the reafler. a. ❑ Drop tube with mechanic�W overfill at 95% ❑ Cold start of monitoring panel : ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection ❑ bverfill prevention (see LG letter 150-1) Other: see below ❑ This VST facility is APPROVED to operate This LIST facility is NOT APPROVED to operate r r 71+ r IL .0 y , 1-1� n ' 'y I !L !i J1 J/ J Jrt!q iriYF f K HIS FACILITY UBJECT TD REINSPECTION AT ANY TIME AT IEHD'S C RRENT HOURLY RATE. EHD Inspector: •� Re Iv y: _,f Title: 0000-,EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT Rev 4/30112 j e;