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OAaU I ,N• ' • .0 <br /> ? ' -•�.E� ' °a SAN JOAQUIN COUNTY <br /> %rr IN ; 04 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468 -3433 Web: www . sigov . org/ehd <br /> CgIF <br /> ClFOR�`P <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> Facility Address : Service Request #: <br /> Onsite Service Technician's Name : ICC Service Technician/Installer Exp, Date : Manufacturer Training : <br /> IN 1 � , UVAN 1012\ / 23 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket � minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial : T9.,\1 hour hydrostatic ❑) ncon TS- STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <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 /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model : psi <br /> 1:1El❑ fail 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 ❑ 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 LIS letter 150- 1 ) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME% AT EHD ' S,CURRENT HOURLY RATE . <br /> EHD Inspector: Received By: - -^ % " Title : <br /> ter <br /> EHD 23-04 N C }C3 ; j 1 �?�� r tiA ' V..e UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />