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*;* 11 " 04F11411 N <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 <br /> c \a % Tele hone: ( 209 ) 468 - 3420 Fax: ( 209 ) 468- 3433 Web : www . si oq v . orglehd <br /> UNDERGROUND STORAGE TAN ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : j� <br /> T, V <br /> Facility Address : Service Request # : <br /> Onsite Service Technician ' s Name : ICC Service Tec ician/ Installer Exp . Date : Manufacturer Training : <br /> Rev _ _ ' <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model : <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS - STS <br /> ❑ electronic Serial # : ❑ Caldwell System ❑ Other <br /> ❑ line test prograrnmed <br /> Leak detector <br /> 11 mechanical Model : - Spill bucket ❑ minimum 5 gallon <br /> C' El El❑ electronic Serial ## : 1 hour hydrostatic ❑ Incon TS - STS <br /> El line test programmed <br /> El Caldwell System 1:1 Other <br /> sensor <br /> Llpositive Shutdown Model : � Parypsi piping testing at: <br /> ❑ fail safe Serial # : _ minutes I I <br /> ❑ N A, <br /> sensor Secondary containment testing fork <br /> ❑ ❑ p slti��/ e shutdown Model : DC ( s) q� Piping <br /> ,A fall safe Serial # : Sump ( s ) UST ( s ) <br /> ❑ INIA _ <br /> sensor Te ting forth above components are next due by : <br /> El positive shutdown Model 6 f er Iks f aU <br /> El <br /> El fail safe Serial # : Note: P !ease be aware that 20 containment components are required to be tested upon <br /> ❑ NA installation , 6 months after, a: �d every 36 months thereafter. <br /> L-1Drop tube with mechanical overfill at 95 °0 El 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 I This UST facilitv is NOT APPROVED to operate c , <br /> O. Uovu f <br /> 0 M0 ie�5 <br /> LI& tD6I` e 0 D%Iap, 11Lr p <br /> 2 ihc oteA+ <br /> yk 0 L o <br /> 11Zc G <br /> THIS FACILITY IS SUBJECT TO AEINSPECTIO TIME Ai END ' S CURRENfI4011 IRIY RATA . <br /> EHD Intgt: � ceiv � ` / <br /> y c ` 3 �v V <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4. 30/ 12 <br />