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_.• _l,_ .Z SAN JOAOUIN COUNTY <br /> y:RNs f {1 ENVIRONMENTAL HEALTH DEPARTMENT <br /> �N� J 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> ...,.CIFpRc�.• <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> , A ': C 2 <br /> Facility Address: Service Request#: <br /> lLiQc) -'s - (vt IOLA" Matto-n� &,&A g,o 0- -e)�1 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer E_xo. Date: Manufacturer Training: <br /> p <br /> SERVICE SERVICE <br /> Lean detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El❑ electronic Serial #: El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> 11 E]❑ electronic Serial #: El hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed ❑ Caldwell System El Other <br /> � sensor <br /> Primar <br /> L] positive shutdown Model: y piping testing at: 1�t��F,f /flf� ��`' <br /> ❑ ❑ fail safe Serial #: gid —psi k <br /> El NA minutes q I C <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 installation,6 months after,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 950/0 ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 9511/0 ❑ 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 /> ov <br /> L4b i � M V,r ',. ' x71 11 0 l <br /> --ill _ �;` , '1V\)C-LXa^ �, :+ r = "12- - 1 0 t- <br /> i'QJ i t v if <br /> I Ao; A <br /> 6-Ad d- ek- �-d CIlA 1 2 sV�C� <br /> THIS FACILITY IS SUBJECT TO REINSPECTI ANY tIME AT END'S CURRENT HOURLY RATE. <br /> EHD Insp t : Recei i3y: Z '-c- <br /> EHD 23-04 �l UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />