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SAN JOAQUIN COUNTY <br /> -cl 1 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.siaov.org/ehd <br /> STORAGEUNDERGROUND T T) PROGRAM SERVICET INSPECTION <br /> Facility Name: Inspection Date: <br /> 01�0 V8 <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> c — - t — <br /> SERVICE <br /> Leak detector <br /> Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System Other <br /> El line test programmed ZoPl <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El❑ electronic Serial #: 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System Other r <br /> sensor <br /> -1 <br /> El positive shutdown, Model: Primary piping testing at: <br /> El fail safe Serial #: ❑ psi <br /> El NA minutes <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 APPROVED to operateThis UST facility is NOT APPROVED to operate <br /> t <br /> C� I as &I <br /> 0 Or <br /> t* - <br /> THIS FACILITY IS SUBJECT TO REINSPECTION ATA Y TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rec ' y: Titip: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />