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•'��''•,� • 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.sioov.org/ehd <br /> '{<IFO •; <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Y UI / ^/G <br /> Facility Address: Service Request#: <br /> 149 5� 1 Ava. % o SR 0073.7 <br /> Onsite Service Technician's Name: ICC ervice Techn cianllnstaller Exp.Date: Manufacturer Training: <br /> Caldwed mare. so/9 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ElElmechanical Model: 1:10 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ElCaldwell System ❑ Other <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> El El mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El —psi <br /> ❑ fall safe Serial#: <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 /> 11 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 below9eC& r Cb r me er <br /> 4-e5+,' n9 <br /> ® This DST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> 0jj5;fW '` g r <br /> Of Ae. eaST' and Wes+ j $V <br /> !1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: - Receive y: ^ Title: <br /> I e K M 64 r+n U/�(/" D.of <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 <br />