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'Op,GLU l y CD <br /> SAN JOAOUIN COUNTY <br /> -+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> y _ 1868 East Hazelton Avenue , Stockton , CA 95205 - 6232 <br /> Telephone : ( 209 ) 46 & 3420 Fax: ( 209 ) 46 & 3433 Web: www . sigov . orq/ehd <br /> q < < Fo4 <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> " con Ao n � q cmt <br /> Facility Address : Service ReclUbst # : <br /> Onsite Service Technician ' s Name : ICC Service Tech n ic ia n/Instalf6e Exp . Date : Manufacturer Training : <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model : El <br /> bucket El minimum 5 gallon <br /> El El El❑ electronic Serial # : 1 hour hydrostatic ElIncon TS - STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector Spill bucket Elminimum 5 gallon <br /> ❑ Elmechanical Model : ❑ El hour hydrostatic El Incon TS - STS <br /> 1:1 electronic Serial # : El Caldwell System El Other <br /> El line test programmed <br /> sensor <br /> El El <br /> shutdown Model : El psi piping testing at : <br /> El fail safe Serial # : p <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 % ❑ Cold start of monitoring pane ! <br /> ❑ Drop tube with mechanical overfill at 95 % 4 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 opera e <br /> Ou \ lv LV" V Q \ i lac <br /> On 4W5 ocabaflP c�- e ent k= m s2u&J2 12 <br /> P 5 ( f s I �. L ,s � v ;-` <br /> M o �. 3- 0 t9 <br /> Q <br /> THIS FACILITY IS SUBJECT TO REINS ECT NAT Y TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD Inspect RIX / Titl <br /> L �� CLI <br /> EHD 23-04 , UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />