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oPa•u I N•.c <br /> SAN aJOAOUIN COUNTY <br /> Q. a ENVIRONMENTAL 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 /> 9�Eli' <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> sc- <br /> Onsite Service Technician's Name: ICC Service T clinician/Installer Exp.Date: Manufacturer Training: <br /> --Ceti <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial: El El hour hydrostatic ❑ Incon TS-STS <br /> 11 line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ElEl❑ electronic Serial #: El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> El <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 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 t� ;i:��i I— t ',i;- y I 't <br /> ❑ This UST facility is APPROVED to pperate ❑ This UST facility is NOT APPROVED to operate <br /> IU -1c <br /> .1 <br /> rem;V) i r)s 10 Ly 0 0 VU <br /> ii ,, tri �r <br /> i t ► Q ►'ti 1^1�t° �`� G -1 Jr-;0-d- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe top;' Received By: /� r / Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />