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SAN JOAQUIN COUNTY <br /> Q. � ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �.�. Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.orgiehd <br /> •9��_—ORS.,, <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name:. Inspection Date: <br /> A'(40-rLo of <br /> Facility Address: Service Request#: <br /> )NCL <br /> C 4� q <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> 11 electronic Serial #: ❑ El hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <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 /> El <br /> 11 fail safe Serial #: ❑ minutes <br /> ❑ NA <br /> sensor Secondary containment testin9-dor: <br /> ❑ ❑ positive shutdown Model: UDC(s) '$-+ Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor X Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: O {-k, <br /> ❑ fail safe Serial #: Note: Please be aware that 2°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 950/,0 ❑ 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 UST facility is NOT APPROVED to operate <br /> J 1 \ \ N IM <br /> V\- -) ", <br /> &U Ck 0 11 A Q- Al 2(1�A <br /> r <br /> THIS FACILITY)IS SUBJECT TO REINSP T ANY E T EHD'S CURRENT HOURLY RATE. <br /> EHD Ins ctor: R eived B Title: <br /> 5 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />