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'o pA!•!1 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209) 468-3433 Web:www.si op v.or /q ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Ins ction Date: <br /> G <br /> Facility A dr ss Service Request#: <br /> R <br /> Onsite Service Technician's Name: ICC Service Technicia Installer Exp.Date: Manufac rer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: F-1 ❑ 1 hour hydrostatic El Incon TS-STS <br /> El electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> El ❑fail safe Serial#: <br /> El DSI <br /> ❑ NA minutes <br /> sensor Secon ary 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 of <br /> F-1 ❑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 facil' y Is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> ont Aje t � 1 <br /> � ! 30 4— fr <br /> mt- 0"SNvileL <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIMIt AT EHD' CURRENT HOURLY RATE. <br /> EHD Ins tor: Receiv Title: <br /> ziEHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />