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SAN JOAQUIN COUNTY <br /> Q: a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> h <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT ` <br /> Facility Name: Inspection Date: f <br /> �I <br /> Wt 619 <br /> Facility Address: Service Request#: <br /> 150t rJ ,, 1+ nQ, R� 64 cW(69 44 <br /> Onsite Servi a Technician's Nam?-,_,, ICC Service echnicianllnstaller Epp.Date: Manufacturer Training:11'16VW�� <br /> -'I6- NSU °x . -13 <br /> SERVICE SERVICE <br /> Leak detector <br /> Spill bucket El minimum 5 gallon <br /> 11 mechanical Model: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System 11 Other <br /> Ll line test programmed <br /> t <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> _sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: OL01 10 lif-1) Sump(s) 7 UST(s) <br /> ❑ NA �--4..t!tr rt <br /> sensor y Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 2°containment components are required'to be tested upon <br /> E] NA installation,6 months after.and every 36 months thereafter. <br /> F-1 Drop 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 eLL) <br /> This UST facility is APPROVED to operate Th' UST facility is NOT APPROVED to operate <br /> s <br /> x ice'" v'st <br /> l MPJ ` 1 Ge v'kt i <br /> t <br /> THIS FA ILITY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I ector: Received gB , T Ti e: , <br /> EHC 23-04 Q UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 + <br />