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SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />PqueN <br />❑ <br />�o..coG <br />SAN JOAQUIN COUNTY <br />❑ electronic Serial #: a <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />❑ line test programmed <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si ov.org/ehd <br />Leak detector <br />❑ <br />UN�D�EFRORGSRUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT T <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />Leak detector I <br />❑ <br />❑mechanical Model: <br />❑ Caldwell System ❑ Other <br />❑ electronic Serial #: a <br />Spill bucket ❑ minimum 5 gallon <br />❑ line test programmed <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />Primary piping testing at: <br />❑ electronic Serial #: <br />psi <br />❑ line test programmed <br />minutes <br />sensor <br />❑ <br />❑ positive shutdown Model: I <br />UDC(s) Piping <br />❑ fail safe Serial #: <br />Sump(s) UST(s) <br />❑ NA <br />Testing for the above components are next due by: <br />S <br />senso4eri <br />❑ <br />❑ positive shutdow <br />Cold start of monitoring panel <br />❑ fail safe I #: <br />Corrosion protection <br />❑ NA <br />Other: see below <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />This UST facility is APPROVED to rs 0' <br />NOT ...• 1 to operate <br />l <br />u. I <br />1 I -100P I aLai <br />EW iw <br />EHD 23-04 <br />Rev 10/06/10 <br />IS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Receiv y: Title: <br />lee <br />UST SERVICE REQUEST INSPECTION REPORT <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />psi <br />minutes <br />econdary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 2° containment components are required to be tested upon <br />installation, 6 months after, and every 36 months thereafter. <br />❑ <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />Other: see below <br />This UST facility is APPROVED to rs 0' <br />NOT ...• 1 to operate <br />l <br />u. I <br />1 I -100P I aLai <br />EW iw <br />EHD 23-04 <br />Rev 10/06/10 <br />IS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Receiv y: Title: <br />lee <br />UST SERVICE REQUEST INSPECTION REPORT <br />