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a <br /> SAN JOAOUIN 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 . sigo\/ . org/ehd <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection ate : <br /> �c � � — ' ! <br /> Facility Address : Servic Request # : <br /> Onsite Service Technician ' s Name : ICC Service Technician/Installer Exp . Date : nufacturer Training : <br /> SERVICE ' SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model : ❑ ❑ hour hydrostatic ❑ Incon TS - STS <br /> ❑ electronic Serial # : Caldwell System ❑ Other <br /> ❑ line test ro rammed <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 /> Primary testing at : <br /> ❑ <br /> El positive shutdown Model : � � psi � � T(� � / � � f J � � <br /> El fail safe Serial # : <br /> El NA &<2, minutes <br /> sensor Secondary 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 /> ❑ El positive shutdown Model : <br /> El fail safe Serial # : Note: Please be aware that 20 containment components are required to be tested upon <br /> 1:1NA installation , 6 months after, and every 36 months thereafter. <br /> r❑ 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 Uju d, . 5C. <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> �a +- 1 add- <br /> coo <br /> --� rl I,tC_ \ - ' C� -- IUB } <br /> !�> > Q) <br /> _ aiiaA Ca) Sao <br /> \ > ` t %� � fel' I h L_ I <br /> cu <br /> C( � b CA <br /> THIS FACILIT IS SUBJECT TO REINSPECTION AT ANY TIME A41EHDYS CU RENT HOURLY ATE . <br /> EHD I ector: Received B • Title : <br /> �tiLC��`l sU5q44LF u,3-c� <br /> D42 u UST SERVICE REQUEST INSPECTION REPORT <br /> Rev4/30/12 <br />