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SAN JOAQUIN COUNTY <br /> Q' Za ENVIRONMENTAL HEALTH DEPARTMENT <br /> y. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ' • 1 .P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> q�IF60 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: 4CC Service TechniciaMns r Fxp.Date: MaVtL <br /> cttturer Training: <br /> r <br /> /0--7,3 iv —Z/, tom. <br /> SERVICE SERVICE <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 /> 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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> El NA minutes <br /> L-;z ti• sensor d'q� r7 Secondary containment testing for: <br /> El positive shutdown Model: L+ UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA — ' <br /> sensor El 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 /> ,,)to This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> :_ <br /> 4.. r 4— —7 <br /> THIS F*ILITY,IS SObJEtf T EINSPECTION AT NY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins Received By: Title: �-- <br /> �' C�erv, /66 <br /> EHD 2 -04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4 2 <br />