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o. e <br /> ?' � '°G SAN JOAQUIN COUNTY <br /> a' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.siaov.orglehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility P <br /> Name: Inspection Date: <br /> E Lt_ I�A I"A� �J -b �2 '?x-R_'9_01H <br /> Facility Address: Service Request#: <br /> l -A 0 �-10_cwicm ? �'� L r� '��-' o g 44 <br /> Onsite Service Technician's Name: ICC Service Tech 'cianflnstaller Exp.Date: Manufacturer Training;, a 111— <br /> ti <br /> SERVICE SERVICE <br /> Leak detector <br /> mechanical Model: Spill bucket F1 minimum 5 gallon <br /> ❑ <br /> I-] electronic Serial #: El 111 hour hydrostatic 11Incon TS-STS <br /> ❑ line test programmed Ll <br /> Caldwell System ❑ Other <br /> Leak detector l <br /> Spill bucket El minimum 5 gallon l <br /> ❑ <br /> F1 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 /> E] F1 shutdown Model: S <br /> El fail safe Serial #: � p <br /> El NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ positive shutdown Model: UDC(s) Piping <br /> E ❑ fail safe Serial #: Sump(s) I UST(s) <br /> 1-1 NA <br /> I sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model <br /> ❑ fail safe Serial #: Dote: Please be aware that 2°containment components are required to be tested upon E <br /> ❑ NA installation,a 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 i <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below f <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> it <br /> Ij <br /> -I beat 0-t <br /> L Or i u_ 1`Aru. <br /> THIS FACILITY ISS BJECT TO REINSPECTION AT ANY YbRE AT EHD'S CURRENT HOtIRLY RAf E. <br /> EHd cctor: Re�,�` ey: Title: .�� I <br /> i <br /> ER[)23-04 _ UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30112 { S P ( / 6� l <br />� l/ f <br />