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oaq�l.. .RECEIVED <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd JUN 1 4 2017 <br /> •KORA, <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> ENVk'UUN MENTAL HEALTH <br /> Facility Name: Inspectionate: -TMENT <br /> ?2 Iq <br /> Facility Address: Service Request#: <br /> es I�t.� v SfiD�K '"` C�"` S <br /> O it Service Technician's Name: IC Service Technician/Installer xp. ate: Manufactur Training: <br /> � � � �� n� <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑electronic Serial#: ❑ El1 hour hydrostatic ElIncon TS-STS <br /> ❑line test programmed ❑Caldwell System ❑Other <br /> Leak detector <br /> ❑mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑line test programmed ❑Caldwell System ❑Other <br /> U ensor <br /> ❑positi e shutdown Model: Primary piping testing at: <br /> ❑fail safe Serial#: ❑ psi <br /> El NA minutes <br /> sensor Secondarycontainment testi o <br /> 9 <br /> ❑ osi iv shutdown Model: UDC(s) �' �� I�k� Piping <br /> fail safe Serial#: Sump(s) LIST(s) <br /> ❑NA <br /> sensor Testing for the above components are next due by: <br /> EJEIpositive shutdown Model: O�,/V)j3 <br /> ❑fail safe Serial#: Note:Please ISe aware that 2°cans 't 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) ❑ Other:see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> _1011MAk4WA ke0 1118 <br /> THIS FACILITY IP SUBJECT TO INS ECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD I p dor � Re ived B Title: <br /> �� <br /> t6R/ 7 HD 23-04 V UST SERVICE REQUEST INSPECTION REPORT <br /> ev 4/30/12 <br /> IYA F„-z� ro <br />