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P�Uiry <br /> SAN JOAQUIN COUNTY <br /> ONVIRONMENTAL HEALTH DEPARTMENT <br /> N > 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fagpity Na e: Inspectio Date: <br /> Facility Address: Service Request#: <br /> O ite Service Technician's Name: ICC Service Te nician/Installer Exp.Date: Manufac rer Training: <br /> l0 W1 <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: <br /> ❑ ❑ electronic Serial#: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed Caldwell System ❑ Other <br /> sensor <br /> El positive shutdown Model: ElPrimarps piping testing at: <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 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 UST facility is NOT APPROVED to operate <br /> QuA Y? V <br /> r <br /> THIS FACILITY IS SUBJEC TO REINSPECTION AT ANY TIME AT EHD' CURRENT HOURLY RATE. <br /> EH I p or: M <br /> ved By: itle: <br /> /A J <br /> E H D 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 C) T <br />