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(Ail <br /> .P°'P.I N•.c <br /> � 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.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> U0 v V'-o o nhr 5tu ren 3 t. 11 20 O <br /> Facility Address: U Service Requ st#: <br /> 1,553 C-C oV' � n GA XR U b:� 83 <br /> Onsite Service Technician's Name: ICC Service echnician/Installer Exp.Date: Manufacturer Training: <br /> lQ-IL - Ll VR-Io VMI - <br /> SERVICE SERVICE <br /> Leak detector <br /> mechanical Model:5j(� ' MLD—}-{G.p Spill bucket F-1 minimum 5 gallon <br /> ❑ electronic Serial #: 131�80�.a,,g El 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial: ElEl1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ 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 2°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 /> rw -- Sf - . 09-t, -v�d <br /> 6L3 - aUovl <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TI E AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec Receiv i��, Title <br /> tt� M W-1- -L40 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />