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SAN JOAQU(N COUNTY <br /> u <i ENVRONMENTAL HEALTH DEPARTMENT <br /> l _ 1868 East Hazelton Avenue, Stockton. CA. 952C5-6232 <br /> Te?epha:ne: 1209) 4c8-3420 Fax:(209) 468-3433 Web:ww,,v.siacv,orgiehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> acility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> p <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> r <br /> •x. .'t 4 .S_'i.. <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial: ❑ 1 hour hydrostatic 11Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System 11 Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor_ <br /> R L- ,::cs'flv9 shutdowt7 t..1,>del: Primary piping testing a:: <br /> i si <br /> . a' safa Serial #: p <br /> minutes <br /> El NA <br /> senso,r Secondary containment testing for: <br /> positive shutdown Model: <br /> UDC(s) Picing <br /> fal sale Sc"riai#: Sump(s� UST(s) <br /> ❑ 'N <br /> sensor LJ 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 /> 3 <br /> ❑ Drop tube with mechanical overfill at 95°0 ❑ 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 /> .etf�.�a�l..- ': �, i1,, r 4i;. Ok ,.�. <br /> t! t) <br /> �( P }} + <br /> .t Y <br /> - F <br /> l � <br /> s!' <br /> ,t o <br /> h t 9 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION"AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Recefyed By:,, Title. <br /> �'(a,•E� r" } +a{.'', <br /> EHD 23-04 - UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />