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A�EJ I N <br /> SAN JOA+QUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> n. I 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.siclov.org/ehd <br /> \ClFC3��` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> m De Col V`ct""tm 121(jf 4l <br /> Facility Address: 121 Service Request#: <br /> j V,015 e0l <br /> Onsite Service Technician's Name: VICC Service Technician/Installer Exp.date: Manufacturer Training: <br /> 2-0 10 l!)Cbk illi <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 111 electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> 1-1 mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ® electronic Serial #: El Caldwell System ❑ Other <br /> ❑ line test programmed <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 /> El NA <br /> sensor ❑ Testing for the above components are next due by: <br /> El El positive shutdown Model: <br /> ❑ fail safe Serial #: Nate: Please be aware that 2°containmentcomponents are required to be tested upon <br /> ❑ NA installation.5 months after,and every 36 months thereafter <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> F] Drop tube with mechanical overfill at 9511% ❑ Corrosien protection <br /> LlOverfill 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 /> on On AVe, <br /> Ali y Af-vl&S 1 14 <br /> 1 ti <br /> ONW�\ ti 1 i'll 'i4 v n one, <br /> ass60 � <br /> S c w�1'� f\ i;wn �nIGin-i' � AVOW C, MWA V 0f G� � tewkS lk+) <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EH 'S CURRENf HOURLY RATE. <br /> EHD Inspecttive or: j Recey: Title <br /> 0 s <br /> rt Chine-1 1I c ✓�- <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30!12 <br />