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O.Pcl'U I N <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN I <br /> N. > < 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.s'gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> � 6v <br /> Fac'itAddress: <br /> Servic�j q�st,#: , 1 <br /> Onsite Service Tjchrnician's Name: ICC Service Technic an/Installer Exp. Da : Manufacturer Training: <br /> lV S <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 /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial:: El 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> El shutdown Model: El Primary piping testing at: <br /> si <br /> El fail safe Serial #: p <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 20 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 USJ;f, cility is NOT APPROVED to operate— <br /> L <br /> M U <br /> r <br /> CA i� irm <br /> tl � <br /> ( --dv <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I ec Receiv d9B : Title: , <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />