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� pL!Ny,r <br /> a• � •.o <br /> _,• _w_,_. ;� SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.swgov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> i uhl -C�,0[ <br /> Facility Address: Service Request#: <br /> ('roti Cj �JC3t;'�1,� <br /> Onsite ServiceTechnician's Name: ICC`Service Tech rhciantinstaIler Exp, Date: Manufacturer Training: -� <br /> Nau I �-b �j eo <br /> SERVICE SERVICE <br /> Leak detector <br /> 11 mechanical Model: Spill bucket Llminimum 5 gallon <br /> ❑ ❑ electronicSerio! #: El E] 1 hour hydrostatic LlIncon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronicSerial #: El El1 hour hydrostatic ElIncon TS-STS <br /> [I line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> i <br /> El positive shutdown Model: P,CIC>J�ry piping testing at: <br /> ❑ ❑ fail safe Serial #: <br /> V psi - 15 ,- �- <br /> j El NA minutes <br /> sensor Secondary containment testing for: <br /> j ❑ ❑ 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 /> ❑ ❑ fail safe Serial #: <br /> ❑ NA Note: Please be aware that 2'containment components are required to be tested upon <br /> installation,6 months after,and every 36 months thereafter. <br /> Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> IQ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> L Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate This UST acility is NOT APPROVED to operate <br /> Lf C X11 - <br /> t ` It1en) _WI Al �iA i Ci t u � t-�a <br /> r <br /> LA C-1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY-RATE. <br /> EHD I ector: Received By: Title: <br /> 4 'tt <br /> Mao (/ t -CW a � <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30112 <br />