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ogctH4N, o <br /> �:.�i••.o '!,/ SAN JOAQUIN 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 SERVICELIST INSPECTION REPORT <br /> rVilFacility Name, Inspection ate: <br /> D -03 Zp63 <br /> Facility Address: Seryce e nest#: x <br /> hIma 00 04 <br /> Onsite ervice Technician's Name: CC Service TechnMrantinstaller Exp..f Date: Manufacturer raining: <br /> 11 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> El <br /> El electronic Serial#: EI ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El 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 /> ❑ fall safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> El ❑ positive shutdown Model: UDC(s�{�b_► ,I �VC> iping <br /> ❑ fall safe Serial#: Sump {s��)cc U ) <br /> ❑ NA ❑ e&fn xt� <br /> sensor Testing for the above pon nts are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: Note: Please Ise aware that 2°containment components are required to be tested upon <br /> ❑ NA - installation,6 months after,and every 36 rtronths 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 UST4;rcititp1s NOT APPROVED to operate <br /> D - D ow-- OA G+ <br /> S( SSOM La (AA <br /> RMu"2611QW, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspecror: Ryceiv By: e: <br /> C� �G <br /> EHD 23-04UST SERVICE REQUEST ECTION REPORT <br /> Rev 4/30/12 <br />