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Or''4UIN <br /> x��'�cOc SAN.JOAQUIN COUNTY <br /> —rte—, z <br /> w: ENVIRONMENTAL HEALTH DEPARTMENT <br /> ', 600 East Main Street, Stockton, CA 95202-3029 <br /> a. P Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.siqov.orq/ehd <br /> 4Ct FORK` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 7— ElLe&*iv M ARV 1112-10 el <br /> Facility Address: Service Request#: <br /> Q3 �i <gouSglw <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Atzy^ P (� sZ5�3 - _ LAT <br /> SERVICE SERVICE <br /> Leak detector <br /> F-1L1mechanical Model: �_Spill bucket Nr minimum 5 gallon <br /> ❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed J4 Caldwell System gpN.M❑ Other <br /> Leak detector <br /> ❑ ❑ mechanical Model: qt Spill bucket W minimum 5 gallon <br /> ❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed 'Caldwell System MOW70 Other <br /> Leak detector Qq Spill bucket tXminimum 5 gallon <br /> El mechanical Model: [�tE 1 hour hydrostatic ❑ Incon TS-STS <br /> 1-1electronic Serial #: <br /> ❑ line test programmed <br /> I�Caldwell System 30ry�n❑ Other <br /> sensor Primary piping testing at: <br /> p <br /> El positive shutdown Model:❑ fail safe Serial #: Ll <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 /> El <br /> ❑ fad 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 /> V S — CJ <br /> l!yi <br /> THIS FACILITY IS SUBJECT TO REI SPECTION AT ANY TIME AT EHD'S CU RENT HOURLY RATE. <br /> EHD Inspector Recei By: Title: <br /> ' A�ql P-0 <br /> EHD�04V46 UV (r/ C),ct� '�12 ILI.l yy,,,,, (/'y'�' fir t'TI-(^/ 11J;T SE EE EKAY NS i It REPORT <br /> Rev 11/17//0✓yt ,� )_ _- J�- , 1 � 1 S�nA (�/� ✓ <br />