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w <br /> QAqufN�ci. <br /> :v. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1 868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sjgov.crq/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspectiondate: <br /> im D e pi pe-�Ybuwy) 101 <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Tech nici n/Installer Exp. Date-. Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ I hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: 171 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 <br /> ❑ ❑ positive shutdown Model: LlPrimar~ppiping testing at <br /> si <br /> ._1 fail safe Serial #: minutes <br /> NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> Q 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: Piease oe aware that 2'containment compcnents are required'o 6e tested upon <br /> ❑ NA installation,6 months after,and every 36 morths thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold stark of monitoring pane! <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 /> of conve 5, m-o- on d' . 2 k <br /> UALC Mli ' 12, 1 <br /> ca ori A I W �d 1n U ' o ct+P 0 • Q <br /> b,1e wlC k U <br /> by iuars 0AU, U 4aMW- <br /> THIS <br /> P . -THIS FACILITY IS SUBJECT TO REINSPECTIONAT ANY TIME AT EHD'S CURRENT HOURLY RATE- <br /> EHD Inspector: 611(Annef Received Tine <br /> l 16 ` <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 <br />