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Zq•�r'.oc �' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> w Lqt < <br /> 4• �1= 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> dt FOR' <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> - Q - 30 =x015- <br /> Facility Address: p service Request#: <br /> U <br /> I J• II Soh S Z)In R I cr <br /> Onsite Service Technician's Name: ICC service Technician nstaller Exp.Date: Manufacturer I raining: <br /> :C Wl t)( `tJ i;--g pIfo Ver ya - I JL-30- I Sj <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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fall 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 /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: Nate Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA installation,6 months atter,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 � �t' <br /> ❑ This UST facility is APPROVED to operate Qct This UST facility is NOT APPROVED to operate <br /> In549- -IvZ5dP-"o -6.ILL ik- sit D , 3 CAST is 30,002ctl x <br /> ao eoo ctIal L-t LF goo Ins <br /> 40(- Lyli 2 L S iA CO A- le J <br /> Dprro5"C)r) vr- Ci ors 1 <br /> IJAdercct iw oti Q.�VOQ.Y1t KG fS L- <br /> ack l aGh " <br /> T IS FACILITY IS ISUBNACT TO REINSPECTION T ANY TIME T EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: ,^ Rece d By / Title: <br /> V 1 11 /6 <br /> EHD 23-04UST(\ UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 C - <br />