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i/a4u�I Nom, <br /> —��, SAN JOAQUIN COUNTY <br /> e' a! ENVIRONMENTAL HEALTH DEPARTMENT <br /> n 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �.`�• P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.crg/ehd <br /> /FORN� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> V-Mn 0a S 5��77� 2'�5 I 2 <br /> Facility Address: Service Request#: <br /> lggo r, Main M" rra <br /> Onsite Service Technician's Name: ICC Service;T�;hnicianflnstaller Exp. Date: Manufacturer Traini g: <br /> 1)0,0 d -I ad o �' z �' x � ' �l I e7 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ 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 <br /> ❑ <br /> El shutdown Model: ❑ Prima piping testing a:: <br /> 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: Piease be aware that 2°containment components are required to be tested upon <br /> El NA installaticn.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 K <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> P 'OP P 11/1 aja r 119 V <br /> y <br /> THIS FAC1LlTY EJECT TO REINSPE,CRON AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect IT R ewed By: 17c, <br /> J <br /> I//n/f 11 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />