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PqU 1,N <br /> SAN JOAGIUIN COUNTY <br /> 2: r—cc�—. .•Z <br /> tn; < 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 /> ��FORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: , Inspection Date: <br /> Facility Address: Service Resigst#: <br /> (y19 <br /> Onsite Service echnician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training/ n <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El El hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> E] ❑ electronic Serial:: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Primaryps piping testing at: <br /> ❑fail safe Serial #: p <br /> ❑ NA minutes <br /> sensor Secondary containment tesfioafor I ply <br /> ElEl positive shutdown Model: UDC(s) #' ri❑fail safe Serial #: Sump(s) US) <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 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 operate ❑ This UST facility is NOT APPROVED to operate <br /> i a t <br /> JCiA <br /> r7 �, <br /> i . ,.� <br /> 'M 16T <br /> T S F ITY IS qUBJg4T TO REINSPECTION AT ANY TIME AT EHD'S dUARENT HOURLY RATE. <br /> EHD Ins o Recei d B Ti <br /> l%K--,' � I <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />