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SAN JOAQUIN COUNTY <br /> Q` 'a ENVIRONMENTAL HEALTH DEPARTMENT <br /> > X 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.siaov.org/ehd <br /> 9 ,1660 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: j Inspection Date:Ul' u/ec. Z 2 Z�J <br /> Facility Address: Service Request#: <br /> `1 <br /> Onsite Service Technician's Name: ICC Service Tech nician/InstaIler Exp.Date: Manufacturer Training: <br /> r ii �r6t2 <br /> SERVICE SERVICE <br /> Leak detectorL5 W "� Spill bucket ❑ minimum 5 gallon <br /> XW-m-echanical Model: Lp---3`ity ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: &&311430 <br /> ❑ line test ro rammed �— ❑ Caldwell System El Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El El1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System El Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <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 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 /> X This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> THIS FACILITY IS SUBJECT TO REINSPE TIO ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins ec r: eceiv y: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />