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PptU t IY <br /> SAN JOAQUIN COUNTY <br /> m; < ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> �aLrFOR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility.Name: Inspection Date: <br /> FacilitV A ress: Servi e R ue t#: <br /> so Vol Ir-mg, bA vk <br /> —Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Ma ut r r Training: <br /> Q , <br /> SERVICE KRVICE <br /> Leak detector V <br /> ❑ mechanical Model: Sp II bucket `minimum 5 gallon <br /> ❑ 1 hour hydrostatic Incon TS-STS <br /> El electronic Serial #: Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector pi bucket minimum 5 gallon <br /> El El <br /> mechanical Model: 1 hour hydrostatic Incon TS-STS <br /> El electronic Serial#: <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment testin for: i <br /> El positive shutdown Model: UDC(s) Pi ing <br /> ❑ fail safe Serial#: Sump(s) 1 T(s) <br /> ❑ NA S j 1 (' <br /> sensor esting for he above components are next du y: <br /> ❑ ❑ positive shutdown Model: iA& 12d2 <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 /> p 1 Cold start of monitoring panel <br /> Dro tube with e h ica ve ill a /o <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 /> - <br /> I Mi rq <br /> e a <br /> I toy rb WOW Ad , <br /> THIS FACII ITY fS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In c r: Re i ed B Title:_ <br /> C <br /> EHD 23-04 ! UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />