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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> EO: <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax.,(209) 468-3433 Web:www.s'qov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> ALC>a <br /> Facility Address. Service Request <br /> LIU-) <br /> Onsite Service Techni iaq's N ah/installer Exp,Date: <br /> Name: Manufacturer Training: <br /> ph4 <br /> qS! <br /> U <br /> SERVICE SERVICE <br /> Leak detector <br /> Spill bucket Ll minimum 5 gallon <br /> ❑ E] mechanical Model: ❑ L-1 1 hour hydrostatic Ll Incon TS-STS <br /> El electronic Serial #: <br /> Ll line test programmed L1 Caldwell System Ll Other <br /> Leak detector <br /> Spill bucket Ll minimum 5 gallon <br /> El mechanical Model: <br /> El El Ll 1 hour hydrostatic Ll Incon TS-STS <br /> El electronic Serial #: <br /> Ll line test programmed Ll Caldwell System Ll Other <br /> sensor <br /> E positive shutdown Model: Primary piping testing at. <br /> El F1 fail safe Serial ff: El psi <br /> minutes <br /> El NA <br /> sensor <br /> Secondary containment testing for: <br /> F1 positive shutdown Model: <br /> ❑ UDC(s) q��ad'6-d �Lj Piping <br /> F1 fail safe Serial <br /> sump(S) UST(s) <br /> F1 NA <br /> sensor Testing for the above components are next due by: <br /> ❑ F] positive shutdown Model: <br /> E] fail safe Serial <br /> Note: Plaase 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 /> ❑ Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> F-1 Drop tube with mechanical overfill at 95% El Corrosion protection <br /> E Overfill prevention (see LG letter 150-1) M, Other: see below <br /> a-D <br /> El This UST facility is APPROVED to operate \0 This UST facility is NOT APPROVED to operate <br /> I. <br /> ry�w <br /> Ailx� WAP- Ce -L Cet -Lk — M4Ao- A'AA <br /> _j[� C <br /> ClkaM Loe X-p,%A-hu Ak'we S + to Qb LQ4 JA QA wm JQ.�4. ,ed DL,,.d Jvud <br /> fylava-Wa CkWa 1),14 'V C Ke LoA--(Q�4 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In tor: Received By: TitleL. <br /> EHD23r JCCLtt,�,. t,Lt kA V, C <br /> Rev 4/30/12 '7e eotjC401LA-'L� UST SERVICE REQUEST INSPECTION REPORT <br />