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n !N, <br /> Vii' SAN JOAQUIN COUNTY `� <br /> .2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> yr <br /> ; :� 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ' Telephone: (209)468-3420 Fax: (209) 468-3433 Web:www,sigov.org/ehd <br /> 4t�FO.�txv <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Teal er liea I reLo 15- <br /> Facility Address: Service Request#: <br /> GO 5 1 QOt yl 5 A 1Ya c3l"i S $ <br /> Onsite Service Technician's Name: I CSentiicce Te nicianllnstaller Exp.Date: Manufacturer Training: � <br /> �� Q. 'V t C/J —Wn — I� <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El El El El electronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> EJ mechanical Model. <br /> El El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor Primary pipi g testin�a4 0515 <br /> El EJ positive shutdown Model: >" psi /1 <br /> El fail safe Serial#: minutes <br /> ❑ NA <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 /> ElElpositive 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 M 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 This UST facility is NOT APPROVED to operate <br /> 0151i-Le, -�o 0 -Pr -k kw%mc)X34 _j <br /> �Lt 't h x l X i - I <br /> ( Q - 5 T5.1 t>ti "Wts �kS <br /> i 5\- -- 15.? 6 .� <br /> QST - , S sk <br /> Iii C) [QCz i iA L n eo e ►to - <br /> THIS FACILITY IS SUBJECT td REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp r: n _ � ^ eived Title: <br /> EHD 23-04 ' IY 11 `G/✓ Q,aj O� UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 (� <br />