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Pqutk pp, a�-q I�3 V <br /> o• c SAN JOAQUIN COUNTY <br /> Q. a ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. < <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sidov.org/ehd <br /> CqC%F OR�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility <br /> Name: Inspection Date: <br /> SGS ©r� - ZE c <br /> Facility Address: Service Request#: <br /> 4200:46461 <br /> Onsite Service Technician's Name: ICC S rvice Technician/Installer Ex e: Manufacturer Training: <br /> DCty, KkA C\ n C1 _ _ 2G 1 k6m.Jo <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F1 ❑ electronic Serial: ElEl1 hour hydrostatic E] Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <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: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <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 /> ❑ NA I 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 Qe4r�,o—d <br /> '(Lp,JO glAke Ik <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOTA PROVED to operate <br /> e VV0,6 , aqx-tj� <br /> C�OOCvr iLt, 40-a041(0 <br /> �Q X33 iq pkovte1 A 'o kA <br /> "Al is h V7 P,r { a h <br /> THIS FACILITY IS SUBJECT TO RE SPECTIO T ANY TIMEAT EHD'S CURRENT HOURLNP RATE. <br /> EHD Inctor: C ReceiveBy: it : <br /> 0 <br /> �j A o, V <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 No-rC , IVDU ywA <br />