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'o¢quty <br /> SAN JOAOUIN COUNTY <br /> „rte ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> cq.•- :::.1;iP.. Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sicov.orQ1ehd <br /> �%FOR <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: 1 <br /> "SIn action Date: <br /> LA Li nS <br /> Flcilil Address: <br /> Ir „ / 7� Service Reques't-#7: <br /> Onsite Service Technician's Name:e I �� G v / <br /> Vn) & ICC Service TechnieiaMnstaller Exp.Date: Manufacturer Training: <br /> I I - 1y- 11 ,Foce.COuc} 5oe�,c is} , LBW <br /> ll g rnS _ .l <br /> SERVICE <br /> Leak detector SERVICE <br /> ❑ ❑ mechanical fro s n <br /> Model: _ Spill bucket El minimum 5 gallon <br /> ❑ electronic Serial#: -1 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed -- ❑ Caldwell System ❑ Other I <br /> Leak detector <br /> ❑ ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> Elelectronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed — ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: Primary piping testing at: <br /> ❑fail safe Serial#: ❑ _psi <br /> ❑ NA _minutes <br /> sensor <br /> ❑ ❑ positive shutdown Model: Secondary containment testing for: <br /> ❑fail safe Serial#: UDC(s) Piping <br /> ❑ NA Sump(s) UST(s) <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑positive shutdown Model: <br /> ❑ fail safe Serial#: <br /> ❑ NA Note: Please Oe aware that 2'containment components are required to be tested upon <br /> installation,6 months atter,and every 6 months thereaNer. <br /> ❑ _ Drop tube with mechanical overfill at 95% <br /> JE] Corrosion <br /> old start imonitoring- <br /> panel <br /> ❑ _ Drop tube with mechanical overfill at 95% <br /> n <br /> ❑ Overfill prevention (see LG letter 150-1) ther: see <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> D LA<_ <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD nspector: <br /> R eived By Title: �+ <br /> EHD 23-04 GL, <br /> Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT <br />