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SAN JOAQUIN COUNTY <br /> Y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.slgoy.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspecllon Date- <br /> c�ol pobir �� <br /> Facility Address: Service Request M: <br /> Onsite Service Techn[clan's Name: ICC S a Teshniclannnslaller Exp-pate: Manufaclurer Training: <br /> 120 00a 2 ?a <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑Incon TS-STS <br /> ❑electronic Serial#: ❑Caldweil System ❑Other <br /> ❑line test ro rammed <br /> Leak detector Spill bucket ❑minimum 5 gallon <br /> El ❑ mechanical Model: EJ ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑electronic Serial#: <br /> El tine test programmed ❑Caldwell System ❑Other <br /> sensor <br /> El 11 positive shutdown Model: El psi testing at: <br /> ❑fall safe Serial#: minutes <br /> ❑ NA <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 El for the above components are next due by: <br /> ❑ ❑positive shutdown Model: <br /> ❑fail safe Serial#: <br /> No a,Please be aware lCdl 2°wnta4unani ' <br /> ❑NA Fq� nts are required to be tested Lp,.. <br /> Inslallal{on.8 nwnihs after,and ovary 1fi morrtRs lhereaRer <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ElCorrosion protection <br /> Overfill prevention(see LO letter 150-1) ❑ Other:see below <br /> This UST facility Is APPROVED to operate ❑ This UST facility Is NOT APPROVED to Operate <br /> Or <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspa for: Rocaivad By. Title: <br /> EHp 23.04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30112 <br />