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0* utry <br /> j,x•�:i''•, • SAN JOAQUIN COUNTY <br /> Jvl Y� `y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:v,rww.sigov.orQ/ehd <br /> 9<1F0 , <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspectio Date: <br /> Facility Address: Service Request#: <br /> CJ, q SQL DC 3 <br /> Onsite Service Technician's Name: Ill Service TechniciaMnstaller Exp.Date: Manufacturer Training: <br /> 5T, \3�p 6A 35N a as t2 V M�-= Q 1� <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> mechanical Model:*N1 I 'aWD ❑ ❑1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: 140 11 \�$4 ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> —c4—Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: 4MT 1X11;It0W ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: 130_)1 C,S ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El _psi <br /> ❑ fad safe Serial#: minutes <br /> ❑ NA <br /> sensor Second ry containment testing for: <br /> ❑ ❑ positive shutdown Model: tj UDC(s) °67 '%9\ Piping <br /> ❑ fall safe Serial Sump(s) I UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: NOJGn+bcr ao��— <br /> ❑ fall safe Serial#: Note: Please be aware that 2D 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 LIS letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> ,; — LA Z. <br /> Allw <br /> THIS FACILITY IS SUBJECT TO REINSPCTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector. y\ Received By: Title: G N <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 I '� <br />