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ow !'•t-h. <br /> ?'mit'•., <br /> ---rte. •y2 SAN JOAQUIN COUNTY <br /> y� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1,SL S4f`, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> .,dtfFOR'r•� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: <br /> NAV\- .�0A 0 V-Ub Inspection Date: <br /> ' 0(0/2-,2.12U1-7 <br /> Facility Address: Service Request a: <br /> 24323 N VAwj 9q , ACGLr)?0 O'E;220 51ZU0 4011Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> 1`1lchue,� 'Y-eAnard ID1--),Ft 1200 <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 E3 minimum 5 gallon <br /> El ❑ mechanical Model: El El hour hydrostatic 11 Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ElCaldwell System ❑ Other <br /> sensor <br /> El ❑ positive shutdown Model: Primary piping testing at: <br /> El❑ fall safe Serial#: psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for. ,' <br /> El positive shutdown Model: UDC(s) _ M&X Piping <br /> ❑ fall 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 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 /> n thm \ l t7i� <br /> r as "6 talaLLEkm <br /> TililreAd-V e ritua.n %s AD e <br /> erg ao, asoxtAe Akii. -kcion r on <br /> o n inti = a secol"hAarg GbyAZktn - <br /> e Y pn <br /> Wok }anvi in accord /.tl <br /> S. <br /> 44 <br /> THIS FACILITY IS SUBJECT Tb REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Re ived By: Title: <br /> F110i a Fwri b servcce ied\m(Auf 1 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30112 <br />