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oP•`•'•Iy c <br /> SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siaov.orcl/ehd <br /> �l FORS` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> — V-Pi� (, 43 2J`l0� 0 �bb`10 <br /> Facility Address: service Request#: <br /> LA <br /> Lf a S � D0s�s��-� <br /> Onsite Service Technician's N e: ICC Service Technicianlinstaller Exp.Date: Manufacturer raining: <br /> k44" Q �a Qq 10 UQ- LPEV 3 X34034 01 U <br /> M D <br /> SERVICE SERVICE <br /> Leak detector Spill bucket F-1minimum5 gallon <br /> ❑ ❑ mechanical Model: 1-1 ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed y <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: 1:10 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test 2rogrammed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ <br /> ❑fall safe Serial #: psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ 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 #: Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA 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 /> ( i t <br /> d�1 I—, <br /> k nl m l 7 <br /> s - d, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION ATAjNY TIME AT EH 'S CIIRRFNT NOUI&Y RATE. <br /> EH nspector: Received B Title:— - <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> 'v(YS l-IC- I i <br /> Criv►ic.�In sZl s IVa CZfhFca tQr� Mee�a{ �uT f`X -s 6+ fbUM nO -F46"W4; r O-A iqg' <br />