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4U/N <br /> ): •..O <br /> _ � SAN.IOAQUIN COUNTY � <br /> a.•r.• �r Z ENVIRONMENTAL HEALTH DEPARTMENT <br /> .t <br /> w: 600 East Main Street, Stockton, CA 95202-3029 <br /> �q . ,j _: :P.• Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> �/FORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facili�r ame: Inspection Date: <br /> l IC, -gic, 03 -19q.2,011 <br /> Facility Address: Service Request#: <br /> [5--3E?rr✓✓ c4 T/ /ri�V'rn/ , �►2[ D o 6 g <br /> Onsite Service Technician's Name: ICC Service Techniciantinstaller Exp.Date: Manufacturer Training: <br /> 4u <br /> 441 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El 1 hour hydrostatic El Incon TS-STS <br /> EI electronic Serial#: <br /> L1 line test programmed ElCaldwell System ❑ Other <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 /> ann4 sensor &K Qh{t p.4, (6rIhP primary piping testing at: <br /> El ❑ positive shutdown Morf*❑ fall safe Serial #: Elpsi <br /> ❑ NA 1H 410W c( rVA minutes <br /> Jnsor Secondary containment testing for: Ottnlht� <br /> ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: 2{y &ar Sump(s) UST(s) <br /> ❑ NA <br /> ensor K W Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown <br /> ❑ fail safe Serial#: Note Please be aware that 2°containment components are required to be tested upon <br /> ❑ 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 /> ❑ I Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> L14s{�, tri 5vm AL2 iCsel ca/ up°W� � ce <br /> ❑ This U favi�i�v is APPR o operate IlR26 This USTfacility is NOT APPROVED to operate <br /> V61:6,W 1Pw-vaW of -T-4 aftVar Ce of q 2 a 4 + 3 = <br /> QZjV1 SPi144 = 3in ROTiH s <br /> Vii iril n yihilalr S S <br /> THIS FACILITY IS SUBJECT TO REINSPEC AT ME AT D'S CURRENT HOURLY RATE. <br /> EHD Insp or: ceived By' Title: <br /> r anfi�F ��� <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />