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utN <br /> SAN JOAQUIN COUNTY <br /> N. ENVIRONMENTAL HEALTH DEPARTMEN(b <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> .. P. Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.orq/ehd <br /> S�/PORN` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: <br /> Inspection Date: <br /> Anb D Aw PAA »I9/j2 , <br /> Facility Address: Service Request#: <br /> w 9�7 Sia din S)dOO&w1� <br /> Onsite Service Technician's Na ICC Service echnicia nstaller Exp.Date: Manufacturer Training: <br /> Cuadalu c�'iMCZ- VP, <br /> SERVICE SERVICE <br /> _Leak detector <br /> ❑ ❑ mechanical Model: _Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> _Leak detector <br /> ❑ ❑ mechanical Model: _Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> sensor <br /> 'positive shutdown Model: I �j Primary piping testing at:XX <br /> jfail safe Serial#: ❑ _psi <br /> ❑ NA _minutes <br /> sensor <br /> L1 ❑ positive shutdown Model: Secondary containment testing for: <br /> s <br /> ❑ fall safe Serial#: UDC(s) Piping <br /> ❑ NA Sump(s) UST(s) <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: <br /> ❑ NA Nota: 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 /> ❑ _Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> WMI-Syed S <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received Title: j <br /> /PCjt N/Cf <br /> EHD 23-04 <br /> Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT <br />