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i\ 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 , si (lov . oro/ehd <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> In <br /> Facility Address : Service Request # : <br /> Ll <br /> Onsite Service Technician ' s Name : ICC Service Tech nicianllnstal� ler ExsLDate : Manufactu er Training : <br /> ,r <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model : Spill bucket El minimum 5 gallon <br /> ❑ El El❑ electronic Serial # : 1 hour hydrostatic ❑ Incon TS - STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model : Spill bucket El minimum 5 gallon <br /> El El El❑ electronic Serial # : 1 hour hydrostatic ElIncon TS - STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> sensor <br /> ❑ El positive shutdown Model Primary piping testing at :si <br /> ��ivCk� � ` <br /> ❑ j2;/Aafail safe Serial # : �`� p <br /> -INA minutes � 0 / '�� <br /> { 5� IZ10 Y �1 <br /> sensor Secondary containment to ting 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 % ❑ 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 This UST facility is NOT APPROVED to operate <br /> 1 0 t �� `� e <br /> • >:•^ _ � �j h�� ..) � ��� , �V �.�.r' 'moi �..� � �.�' Y-- (�st�� tr��:o.-- <br /> THIS FACILITY IS SUBJECT TO REINSPEC T ANY TBiVIE AT EHD ' S CURRENT HOURLY RATE . <br /> EHD Inspector: Re ived By: Tit <br /> r-L <br /> EHD 23-04 ST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />