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opAHl.N.. <br /> ?� �''••o SAN JOAQUIN COUNTY <br /> %0e=-NVIRONMENTAL HEALTH DEPARTMENI"M4 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> 4�f F ORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspectign Date: — <br /> c0 X021 �L/ <br /> Facility Address, Service Request#: <br /> 6 i G4 2,9V S ss�t 52aa4M <br /> nsite Service Tel nician's Name: ICC Service Tec nic anllnstaller Exp.Date: Manufacturer Y' 024-90 <br /> r 'ning: <br /> 6-22 ISP l2-IS-I l i/R4-J0'q <br /> SERVICE SERVICE <br /> _Leak detector kl2fSpill buckets minimum 5 gallon <br /> ❑ ❑ mechanical Model: W1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test proqrammed <br /> AwWW sensor-Ltbvi70 Primary piping testing at: <br /> ❑ positive shutdown Model: &' ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> 54T 5tml sensor Wwii4l UST Secondary containment testing for: <br /> p� ❑ pbsitivel shutdown Model: _ 310J- 2- UDC(s) Piping <br /> ❑fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Lt „� I�dr ?, e'k ❑ Testing for the above components are next due by: <br /> ❑ ositive shutdown Model: �4 W- (A <br /> ❑failsafe 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) 11� Other: see below <br /> A+C. Ali <br /> El This UST facility is APPROVED to operate 0 This iF s T APPROVED to operate <br /> A <br /> IN AIL AN 5A45 <br /> t 8�SA6 � {IJb �l t,+3+M1 zo <br /> S <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspecto Recall By: ITAle^ <br /> Or'GN.n�. <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />