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SAN JOAQUIN COUNTY <br /> ya ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> a Telephone:(209)468-3420 Fax:(209)468-3433 e :www.sigov.or /g ehd <br /> STORAGEUNDERGROUND T (UST) PROGRAM SERVICEINSPECTION <br /> Facility Name: Inspection Date:, <br /> Facility Address: Service equ st <br /> Onsite Service Technician's ame: ICC S rvice Technician/installer Exp.Date: Manufacturer Training: r /S ®r <br /> o <br /> ® 7 <br /> ,p <br /> SERVICE SERVICE <br /> Leak detector Spill ucket i n i m u m 5 gallon <br /> ❑ ❑ mechanical Model: hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: ❑ Caldwell Systemther �+ <br /> i c°h <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test ro rammed <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 ro rammed <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 /> 0 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 /> ❑fall safe Serial#: Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA Iinstallation,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 FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME T EHDIS CURRENT HOURLY RATE. <br /> EHD Insp Re iv By: _ :&Titl <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/171/08 <br />