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SAN JOAQUIN COUNTY <br /> tNVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.s4gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> ��_9 ', <br /> Onsite Service Technician's Name: ICC Se a echnician/Installer xp.Date: Manufacturer Train g: <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 El minimum 5 gallon <br /> El ❑ electronic Serial: ElEl1 hour hydrostatic ElIncon TS-STS <br /> ❑ lin test programmed <br /> El Caldwell System 11 Other <br /> LbZ sensorG�rY1D� Primary piping testing at: <br /> positive shutdo n ❑ psi <br /> ❑ fa i e—�" Serial#: <br /> A minutes <br /> sensor`i1l 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 <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> is Dr a z <br /> SL <br /> -SLI 914 <br /> � dgnCe_ �f w215 <br /> i Qa 3 0 q4 4ui6town k �l t? Z- v WCA,,um <br /> cwicti n & VI e ( -A Cr rliar II-I-sl J�_ <br /> THIS FACILITY IS SUBJECT 11170 REINSPECTION AT ANY TIME AT EHD'S CU RENT H URLY RATE. <br /> EHD Inspec J;Re�c ' ed Title. C&UALF Lf. <br /> � lel <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />