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Op'•4u IN••.0 <br /> SAN JOAQUIN COUNTY <br /> e: k _NVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> 4<<F ORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> GOO,&— <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: Ice Service Technician/Installer Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> 1-1 mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> —Vft^ sensor n Primary piping testing at: <br /> ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial#: <br /> A 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 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 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 UST facility is NOT APPROVED to operate <br /> UCLA v— 94ri <br /> nnoo4A v°`G 0. F 4— Lt^ <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe Received By: Title: <br /> • � U d � 7 /J� <br /> IV- <br /> EHD 23-04/ZUST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />