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OPp•U IN C <br /> SAN JOAQUIN 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 /> oq<i F oaN�P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: r � Inspection Date: <br /> 1 < <br /> i. <br /> Facility/Address: Servic quest#: <br /> � 5 <br /> ts?Mrvice Tec�ician.i me: ICC Service Technician/Installer Exp.Date: Manufacturpr7 i ai rg: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ 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 ❑ minimum 5 gallon <br /> ❑ El❑ electronic Serial #: ❑ 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> 11 fail safe Serial #: <br /> F-1 NA minutes <br /> sensor Secondary containmen te$tin for: Y <br /> El El <br /> positive shutdown Model: _ Ul 1 Piing" <br /> Elfail safe Serial #: Sump(s) Uf ill <br /> El 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 lJ6T4aeWty4s APPROVED to operate is NOT APPROVED to operate <br /> L, <br /> S i <br /> rl <br /> L f <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY T-IPE AT EHD'S CURRENT HOURLY RATE. <br /> EHD ins Vector: Received By: t Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />