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'oPQu I,N .co <br /> SAN JOAQUIN COUNTY <br /> rn { NVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 9�/FORS` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> i <br /> -z-7--)3 <br /> F cility A-ryddress: Service Request#: <br /> 3 L,1,5 a� <br /> Onsite Service Technician's Name: ICC Service Technicians Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> El positive shutdown Model: psi �+p►— <br /> ❑ fail safe Serial#: <br /> ❑ NAminutesS 5 <br /> sensor Secondary containment testing for: <br /> El ❑ positive shutdown Model: UDC(s) gi + ,Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due b <br /> ❑ ❑ positive shutdown Model OU <br /> ❑ fail safe Serial#: Note: Pleas hat 2°containment components are required to be tested upon <br /> ❑ NA installatio 6 mon hs afte 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 /> e� <br /> 41 <br /> THI FACT ITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp R niveBy: Title: <br /> EHD 23-0 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/ 2// <br />