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¢QUIry C <br /> �°•��'••.o� • SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENTS <br /> ' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www sioov.o[g1ehd <br /> 9<i F o'RN� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Csw sd X6-29-13 <br /> Facility Address'. Service Requesst7#: '7 <br /> Ons a Service Technician's Name: IC Service Te hnician/Installer Exp.Date: �panufact{lrer_Training: ` t <br /> Off(* _l ll DD�NN1I <br /> SERVICE SERVICE <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 /> _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 ry I ing t tin at: <br /> ❑ ❑ positive'shutdown Model: ❑ psi L . I G 1;6 AL <br /> ❑ fall safe Serial#: minutes `P� <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 Elsensor 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 950%lo ❑ 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 /> U SfSid <br /> n <br /> 1 &S T Od_ Ax <br /> quz Mmm�s '98m 00+ ANDI r In n IA 9 <br /> C cQ.l — `r I b' — <br /> sl Fagliu>rl <br /> THIS F CILITY IS SUBJECT TO REINSP T AN IME AT EHD S CURRENT HOURLY RATE. <br /> ' <br /> EHD In r Re Title:C&nsl=/5[JJG e; <br /> Sf.RvrCE� g� <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />