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OQquIN c <br /> SAN JOAQUIN COUNTY <br /> W WNVIRONMENTAL HEALTH DEPARTMEN <br /> AI <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.orq/ehd <br /> Z605 <br /> UNDERGROUND <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit Name: Inspection Date: <br /> Facility Address: Service Request#. <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> r 5 <br /> 7112d 15 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: pill bucket ❑ minimum 5 gallon <br /> ❑ hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <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 /> ensor <br /> ❑ positive sHutdown Model: J(� ZD`ri Primary piping testing at: <br /> El psi <br /> ❑fail safe Serial#: Ifi��,, <br /> minutes <br /> [!fNA . I��k t �- i 11e. — <br /> sensor r�- � a. �—,,o K� Secondary containment testing for: <br /> Elpositive shutdown Model: k ;Q 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 21 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 /> /r=? This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Ad 4--o <br /> THIS FACILITY IS SUBJECT TO REINSPECTIO ^T ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe Received Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />