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AOUtp_ _. <br /> O "•..0 _ <br /> AN JOA®UIN COUNTY <br /> 2 y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> P Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> SGiFORN` <br /> UNDERGROUND STORAGE TANK ( 1ST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> l' c�Iky Name: -� Inspec ion Date: <br /> I l t^ 3 I f� l,2/�.. P O 2—A- <br /> acility Address: Servi a Request#: <br /> 15709 N ext VL bA' Cos 1Li a� ctt b 8 �f� l� <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training; <br /> MILJ A �LaSesh 7`a+ kl 4,u <br /> U 1 �� ul- r <br /> SERVICE SERVICE <br /> Leak detector QOb Spill bucket minimum 5 gallon <br /> ❑ ❑ mechanical Model: K1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: 11 Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> L1 El <br /> mechanical Model: ❑❑ electronic Serial El hour hydrostatic El Incon TS-STS <br /> #: El Caldwell System 11 Other❑ line test ro rammed V <br /> R I in V sensor ryry /, <br /> 11 positive shutdown Model: L 0Ir Primary piping testing at: i es:eC, 7i j <br /> El fail safe Serial#: psi <br /> 11 NA �^ 6 U minutes <br /> sensor Secondary containment testing for: <br /> E] 11positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) LIST(s) <br /> 1 <br /> 11 NA sensor Testing for he ab vecomronents`a{redue by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial #: Note: Please be aware that 2-containment components am required to be tested upon ' <br /> ❑ NA installation,6 months after,and every 36 months thereafter, <br /> SAO 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 /> ❑ his UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> G'i /sz � USi <br /> 0 v Q r l 4 tr 1 'h <br /> Ail�`G� L <br /> Qr`l IWC i to <br /> a Y ly e� rxV S- r d <br /> G C 0 rgQ , <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I epector: ` Rec lived B <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />