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a°'P4 �'••p L SAN JOAQUIN COUNTY ~ <br /> e• w :y <br /> wc• . •, � ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.siooy.org/ehd <br /> <r o: <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Wsirm 3#M <br /> Facility Name: Inspectio Date: <br /> AY-60 AIVA <br /> Facility Address: Seryee Request#: <br /> ,� srz �r��3A9 <br /> Onsite S rvice Technician's Name: ICC Service T hnlcian/Ins Iler Exp.Date: Me acturer Training: <br /> 3 � o olZ <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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ _psi <br /> ❑ fall safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA ❑ <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑fall safe Serial#: Note: Plesseb aw ethat 2°canlainmenlaamponentsare required tobetested upon <br /> ❑ NA nstallation,6 months after,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 /> Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ❑ This UST facihi� is APPRROV, D t perate This UST facility is NOT APPROVED to operate <br /> YL, �� S <br /> 01 sks,7,6 & W 13 C,pa/ <br /> tt IR <br /> tr <br /> t` _ <br /> ir <br /> IM- 3/y�' _ t <br /> & ` pr PIA njaz <br /> H FA ILITY IS SUBJECT T REINSPECTION AT ANY TIME AT EH S URR T HOURLY TL <br /> EH or: Recei Title: f'P� <br /> EZ <br /> EHO 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10106/10 <br />