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/ �auf� C <br /> �•'�� '•O� SAN JOAQUIN COUNTY <br /> w { ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.slgov.org/ehd <br /> C�Q�F Q•12�/ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> N ---A A—2.0 <br /> Facility Address: Service Request#: <br /> 13C(q . OSekV <br /> �lvQ. M mac . �- <br /> Onsite Service Technician's Name: ICC Servie <br /> t Technician/Installer Exp.Date: Manufacturer raining: <br /> 5 ►- g - — 6-16-1-4 -a- <br /> SERVICE SERVICE <br /> Leak detector Pv <br /> iechanical Model: V Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El electronic Serial: El 1 hour hydrostatic 11 Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> ❑ <br /> El positive shutdown Model: ElPrima ps piping testing at: <br /> El fail safe Serial#: p <br /> ❑ 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 /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: 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) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> ttiS i B vQ 4_(AQ b0+ e__ Ll Vt Q <br /> I VLIS _\ 11-F- e d <br /> L LIT <br /> io v - e w�,�1 �-e �=c v s , �h -1 -x_0 j <br /> -00--1 `-VA a. r s • ste oape , <br /> THIS FACILITY IS SUBJECT f0 REINS CTION AT ANY TIME AT EHD'S C RRENT HOURLY RATE. <br /> EHD Iri or: Received By: Title: <br /> ;ikeA 'INNa n <br /> RHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30112 <br />