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OAgttl <br /> SAN ,10AQUIN 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.sogov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> C 05tc o Ga s o l'une, a e i - g !: G 16, <br /> Facility Address: Service Request#: <br /> 3Z 5 d W, Crrr�►-it L`� h _R o rc c , `f�r�c� SR 007-4,34-9 <br /> Onsite Service Technician's Name: ICC Service echnicianlinstaller Exp. Date: Manufacturer Training: <br /> Sau Car, z� �f 9 a51.2 <br /> 1�. �NccfN 4�� 1JI� L�Yei4 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Madel: ❑ 711 hour hydrostatic LJIncon TS-STS <br /> El electronic Serial #: F1Caldwel�S stem LJ Other <br /> El line test programmed y <br /> Leak detector Spill bucket El minimum 5 gallon <br /> Ll ❑ mechanical Model: ❑ El hour hydrostatic ElIncon TS-STS <br /> LJ electronic Serie! #: y <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> El positive shutdown Model: ❑ psi <br /> Primary piping testing at: <br /> F1 fail safe Serial #: <br /> ❑ NA minutes <br /> sensor Secondar containment testing for: Y4IVe-- <br /> ❑ ❑ positive shutdown Model: f UDC(s) Alvove�MeArPiping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: <br /> Note, Please be aware that 21 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) X Other: see below <br /> J9 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> THIS FACILITY IS SUBJECT TO REINSPECTION ATA lM AT EH ' 'CURRENT URLY RATE. <br /> EHD Inspector: Received By: Title: 1, <br /> EHD 23-04 UST SERVICE REQUEST INSPECT N REPpRT <br /> Rev 4/30112 <br />