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oP°�� IN••.c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT N. >{ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s*gov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility a r t, Inspection Dater F 'litAddr ` Service Request #: ❑ electronic Serial #: Wervice Technician's Name: IC Service Technician/Inst Iler Exp. ate: Manufacturer Training: ❑ mechanical Model: i ❑ electronic Serial #: ❑ SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: i ❑ electronic Serial #: ❑ ❑ line test programmed sensor K positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor post ive shutdown Model: ❑ ❑ fail safe Serial #: ❑ ❑ NA FE:710ther: sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) This UST facility is APPROVED to operate W SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS EHD _� ❑ Caldwell System ❑ Other i Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 20 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection FE:710ther: see below W ❑ This UST facility is NOT APPROVED to operate EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT TH!P,F TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY EHD _� i EHD 23-04 Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT