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*gUly <br /> a'�*'•.�2 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT1868 East Hazelton Avenue, Stockton, CA 9205-623 <br /> 2 <br /> Telephone: ( ) (e) t33 igo <br /> v.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> M� on + Fa51 O <br /> Facility Address: Service Request#: <br /> ID 2-12Al 9 9 n C A q5 Qo IS S�Cp <br /> Onsite Service Technician' Name: ICC Service.Technician/Installer Exp.Date: Manufacturer Training: <br /> V\2 CC I --1u - 1 VA -Y-- 9-1L)-I(9 <br /> SERVICE SERVICE <br /> CA I Leak detector Spill bucket ❑ minimum 5 gallon <br /> Kmechanical MOdel:99Lr)-2QQ0 ❑ Ll1 hour hydrostatic ❑ Ineon TS-STS <br /> El electronic Serial#: J to 01 13a$^ <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Ineon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El ❑ positive shutdown Model: ❑ _ psi <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 /> ❑ ❑ 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 alter,and ovary W 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 /> 14 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> O <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Ftpeived By, Title: <br /> I 50d <br /> Jcr�rc� Tach <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />