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oP4ufN c <br /> z.�• p SAN JOAQUIN COUNTY to <br /> N:7c. ENVIRONMENTAL HEALTH DEPARTMENT <br /> 4"IjiM 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sioov.oro/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: <br /> I G� n A rLo ^ , Inspection ate: <br /> Facility Address: 'c-!J (�1/I 1 Z �� ) <br /> Service Request#: �7 <br /> Onsite Service Technician's aw: eFz tc � n�- Dzv�' �t0 G <br /> ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> 2b a- rY Y `� 6 I, v 2 <br /> SERVICE 7en <br /> ERVICE <br /> _Leak detector <br /> ❑ ❑ mechanical Model: bucket ❑ minimum 5 gallon <br /> 11 electronic Serial #: ❑ ❑ 1 hdrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ CaSystem ❑ Other <br /> Leak detector <br /> ❑ ❑ mechanical Model: _ bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hdrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caystem ❑ Other <br /> Leak detector❑ mechanical Model: ucket❑ ❑ minimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Calystem ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ fail safe Serial #: ❑ psi <br /> ❑ NA _minutes <br /> ❑ sensor JE] Testing <br /> econdary containment testing for: <br /> ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: UDC(s) Piping <br /> ❑ NA Sump(s) UST(s) <br /> S ensor for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: <br /> ILI A Note: Please be aware that 2°cantainment components are required to be tested upon <br /> NEICorrosion <br /> llation.6 months after,and every 36 months thereafterDrop tube with mechanical overfill at 95% ld start of monitoring panel <br /> Drop tube with mechanical over ill at 95% protection <br /> rfill prevention (see LG letter 150-1) er: see below <br /> ^Ar <br /> i r1Q<Sf (� U �X- <br /> F rr CPT12 <br /> THIS FACILITY IS SUBJECT TO REINSPE AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I ector. R eiv d <br /> Title: <br /> A (M a <br /> EHD 23-04 <br /> Rev 11/17//08 UST SERVICE REQUEST INSPECTION REPORT <br />