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qui / <br /> �o. .coG SAN JOAQUIN COUNTY <br /> 0404 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N Z <br /> i " 1868 East Hazelton Avenue , Stockton , CA 95205-6232 <br /> c u i o Telephone: (209) 468- 3420 Fax; (209) 468-3433 Web: www . sigov . org/ehd <br /> F0 <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: inspec ion Date: j <br /> �D L I � C I <br /> F cility Address : l Service Request #: <br /> Onsite Service Technician's Name : [cc Service Technician/Installer Exp. Date : Manufacturer Training : <br /> Al g'h <br /> SERVICE SERVICE <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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model : ❑ ❑ 1 hour hydrostatic ❑ Incon T&STS <br /> ❑ electronic Serial # : ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> El ❑ positive shutdown Model : El psi <br /> ❑ fail safe Serial # : <br /> ❑ NA 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 /> ❑ ❑ positive shutdown Model : <br /> ❑ fail safe Serial # : Note: Please be aware that 20 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% ElCold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% El 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 /> le� Pc � <br /> J j 61 Pre- <br /> tr win, ' c ajv� GZ oy (ice Lj a -^ W 4S <br /> a <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD Iector: Received By: Title : <br /> 7 G 14- S' <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />