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�qutq•.' SAN JOAQUIN COUNTY <br /> \./ENVIRONMENTAL HEALTH DEPARTMENT.. <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> v 'P <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.oro/ehd <br /> 4<l F Sat' <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: ' {D�I Ins action Date: <br /> 1 - 113- i <br /> FacWAddrbService Request#: <br /> ss' <br /> Q-650 1 n �c �•b . SM5501 <br /> Onsite Service Technici n's Name: ICC Service Technician nstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <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 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 programmed <br /> sensor Pri ryA6 testing at: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: psi <br /> El NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> El ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: Note: Please be aware Nat 2°containment components are required to be tested upon <br /> ❑ NA installation,6 months alter,and every 36 mons 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 /> ❑ Ove lI prevention (see LG letter 150-1) Other: see below <br /> ���---,,,///111 1 <br /> El This UST facility is APPROVED to operate q[y This UST q 'IsvNOT APPROVED to operate <br /> e / c V <br /> tJEL� N sT <br /> <�A <br /> t <br /> 5� kjW1.NV 6N 5PSI newt/ <br /> Bir � a 'tit <br /> WowAtuw W#A- <br /> LAhWA "10V hr I <br /> Vet `w, to <br /> THIS FACILITY IS SU ECT TO REINSPECTION AT ANY TIMIE AT EHD'S CURRENT HO RLY RATE. <br /> EHD InspeG Recei d By: Tit <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />