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4�IN 0 <br /> >°•;,�es'••.p . 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 /> FO <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> pl0 6b'►S `' <br /> Facility Address: Service Requesf#: <br /> asoo vi. >roal: Ave LodiCA 9sdya SR00 ?603t <br /> Onsite Service Technician's Name: ICC Se ice Technician/Installer Exp.Date: Manufacturer Training: <br /> G 1 ne Niwtr'O Tans4re/ 3 31 1ef <br /> SERVICE SERVICE <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ 111 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: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: )Tjp <br /> 60 si <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 /> El ❑ positive shutdown Model: <br /> ❑ fall safe Serial #: NotePlease 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 /> 6Servee/ P+mU + +n fesfIvi on 7he 8"7 prooluct grwl 9i r"vcI <br /> bries. satt, POP'slrsiizil of O f s/ r6r 30 mi'ndks. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector W�/rAReceived By:. <br /> EHD(23/—e0,4f UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />