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PQU I Iy. <br />>oE -coG SAN JOAQUIN COUNTY <br />OENVIRONMENTAL HEALTH DEPARTMEN <br />10 <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.orq/ehd <br />9�i'9 <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Fac' ' Name: <br />Inspecti n Date: <br />Fqqfflty Address: <br />Service Request#: <br />❑ electronic Serial #: <br />THIS fACALj1TYUBJEC;TO REINSPE ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Ofisite Service Technician's Name:ICC <br />Service Technician/ staller Exp. Date: <br />Manufacturer Training: <br />❑ <br />�-1. - <br />V <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />SERVICE <br />Leak detector <br />❑ <br />❑ mechanical Model <br />❑ electronic Serial #: <br />THIS fACALj1TYUBJEC;TO REINSPE ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ line test programmed <br />❑ <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Cel ensor <br />posi ve shutdown Model: D r <br />ail safe Serial #: <br />El NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />sensor <br />❑ <br />❑ positive shutdown Model: <br />❑ fail safe Serial #: <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />1 This UST facility is APPROVED to operate <br />SERVICE <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />THIS fACALj1TYUBJEC;TO REINSPE ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour 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 />❑ <br />Testing for the above components are next due by: <br />Note: Please be aware that 2° 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 />❑ <br />Other: see below <br />❑ This UST facility is NOT APPROVED to operate <br />D <br />THIS fACALj1TYUBJEC;TO REINSPE ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspector: <br />g� <br />By: Title: <br />Ree'jd t5� <br />�i <br />EHD 23-04 `f UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />