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NCL ty <br />SAN JOAQUIN COUNTY <br />N .{ NVIRONMENTAL HEALTH DEPARTMEN <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />0 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility <br />Inspection Date: <br />yNName: <br />: <br />❑ <br />Facility Address: <br />Service Request #: <br />% ( <br />33x5 <br />[y <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: I/ <br />❑ <br />❑ mechanical Model: <br />SERVICE <br />1 <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />THIS FACILITY IS SUBJECT TO REINSPE9TION AT NY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />R e' ell <br />V <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ line test programmed <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />FE <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />IF] <br />Overfill prevention (see LG letter 150-1) <br />�i This UST facility is APPROVED to operate <br />SERVICE <br />1 <br />Spill bucket ❑ minimum 5 gallon <br />LI9 <br />1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System Other <br />THIS FACILITY IS SUBJECT TO REINSPE9TION AT NY TIME AT EHD'S CURRENT HOURLY RATE. <br />fL <br />R e' ell <br />V <br />Spill bucket Elminimum 5 gallon <br />LJ <br />amour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />Primary piping testing at: <br />❑ <br />psi <br />minutes <br />Secondary containment testing for: <br />UDC(s) Piping <br />Sump(s) UST(s) <br />Testing for the above components are next due by: <br />_`3"� tv -71 13 <br />Note: Please be aware that 21 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 />FE <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 <br />Rev 4/30/12 <br />Cf <br />d" UST SERVICE REQUEST INSPECTION REPORT <br />THIS FACILITY IS SUBJECT TO REINSPE9TION AT NY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins <br />R e' ell <br />V <br />Title:,... <br />EHD 23-04 <br />Rev 4/30/12 <br />Cf <br />d" UST SERVICE REQUEST INSPECTION REPORT <br />