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Pqu l yy <br /> �o. ,t.coG SAN JOAQUIN COUNTY <br /> Q: -+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> y. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit Name: Inspection Date: <br /> Facility Address: Service Re uest#: <br /> Onsite Service Technician's/Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> 1V_ !7 /O UF_ <br /> = 3 1fJ / a <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 /> 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 /> ❑ fail safe Serial#: minutes <br /> ❑ NA <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 ar are that 2°containment components are required to be tested upon <br /> 11 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 /> l5 +� j�L f" cin n�I� t7'-{ S�..s r lug ►-�4- Flo I r4p -q�( 11(-Irl�--- <br /> - --� A Aa—�n—(�"�`a ��i r�i r^� >''��� '�t5 r�-•�Sar , �� <br /> THIS FACILITY IS SUBJECT TO REIN ECTION AT ANY'GIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD to Receiv d By: Title: <br /> UST SERVICE REQUEST INSPECTION REPORT <br /> EHD 23 <br /> Rev 11/17/i08 <br />