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ut <br /> 7 SAN JOAQUIN COUNTY <br /> N. _< *ENVIRONMENTAL HEALTH DEPARTMENT <br /> IP <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> F <br /> UNDERGROUND STORAGE TANKK (UST) PROGRAM SERVICE REQUEST INSPECTION <br /> TIO REPORT <br /> Facility Name: Inspection Date: <br /> r <br /> Facility Address: Service Request#: <br /> ti <br /> E&Q rvic Technician's Name: BC Tech ian/ s er Exp.Date: ufactur T <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: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> ❑ ❑ positive shutdown Model: E] Primaps 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 2°containment components are required to be tested upon <br /> ❑ NA I 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 A PROVED to operate This LIST facility is NOT APPROVED to operate <br /> 1 <br /> 1,fir <br /> Of <br /> [Vle'll, ti <br /> U I — - I I i I <br /> mfivP,. fj. <br /> _wkcmj ,6,c <br /> THIS FACILITY IS SUBJECT TO REINSP C ON ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In tor: Re d Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />