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�''�r•'•O� SAN JOAOUIN COUNTY M <br /> ^�� 2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> a: a <br /> y' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> •_ Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s'gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> oe- eS Mint; ar 2-) 30/[S <br /> Facility Addr Service Request#: <br /> &Ez N. �i 88 Li, i-,e orA , n j 5'2-40 D043890 <br /> Onsite Service Technician' Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> Fr 13A1� '212.0/-2017- VMI I(-)17/ 17 <br /> SERVICE SERVICE <br /> > Leak detector <br /> mechanical Model: M L� 2 000 —Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: 12C I El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> __ <br /> Ll ❑ positive shutdown Model:❑fail safe Serial#: ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fall 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 V 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 El This UST facility is NOT APPROVED to operate <br /> 90etas Q�ec�o✓ A �A <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Recrelved By: Title: <br /> EHD 23-04 UST SER ICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />