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3•'��E�' ..c SAN JOAQUIN COUNTY <br /> �r ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ' Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.siaov.ora/ehd <br /> dt/FOR <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Nam Inspection Date: <br /> 31 /15 <br /> Facility Address: Service Request#: <br /> 2356 -P, I e�� �. S �I 7, <br /> Onsite Service Technician's Nan <br /> e: ICC Service Techniciantinstaller Exp. Date: Manufacturer Training: <br /> tillt 9 S gcr�o s 1 S <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> E] ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial#: El1111 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El _psi <br /> El fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> El ❑ 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 /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> t 4-Z Q \ lttls IV) d� (tilmon 1 ) I <br /> 1� toy ✓t�Zs <br /> (nd A �- BA D� - <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIYAE AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector � Receive - Title: <br /> 1/✓ 491 Ili Arz <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />