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p4..!N• <br /> a°• <'•.o� SAN JOAQUIN COUNTY �r <br /> .2 ENVIRONMENTAL HEALTH DEPARTMENT <br /> ��y,tl 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �1Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> \liFpRi+` . <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> o C-() 0IZoI6 <br /> Facility Address: ServicRequAlst#: <br /> 92sW.. p3,, Li n e C .S 9 <br /> Onsite Service Technician's Name: !CC Service Technician/Instal Exp.Date: Manufacturer Training: <br /> -jarod 1 1161zl- <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El11mechanical Model: El El <br /> 1 hour hydrostatic 111 Incon TS-STS <br /> El electronic Serial#: <br /> El line test programmed ElCaldwell System ❑ Other <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 <br /> ❑ ❑ positive shutdown Model: ❑ Primarypiping testing at: <br /> E] fail safe Serial #: psi <br /> ❑ NA minutes <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#: Not Please be aware that P containment components are required to be tested upon <br /> 1:1 NA installation,6 months atter,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) >j Other: see below <br /> �I This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> D t� e -F n AT ibeS <br /> 191 ) r tr <br /> G <br /> and Act, le4k. <br /> Jarod a , z •sal <br /> ri clnsurli& CE 4hp, 5k Iv c -t <br /> e e v,!-- r'o e5 <br /> IJ s nf j2f-Odvllrdl'.� ver n <br /> THIS FACILITYIS SUBJECT TO REINSPECTION AT ANY E AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins ector. Received By: Title: <br /> C 1 �C�ca- (21l., a-,4 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />