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�Aq J II N. <br /> •' O <br /> i?' � 'O• SAN JOAQUIN COUNTY <br /> Q. ENVIRONMENTAL HEALTH DEPARTMENT <br /> y.ICA 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 7. Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.orp/ehd <br /> 9.CiFpRN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Datq: <br /> Facility Address: Service Request#: <br /> 3Zl'2 N, a St, to� S'R00--7g1�3q <br /> Onsite Service Technician's Name: ICCService echnic' xp. Date: Manufacturer Trainin <br /> OFU-) 1C)hdf=Q <br /> SERVICE SERVICE <br /> Leak detector <br /> [I mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El❑ electronic Serial #: ❑ 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell 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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <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 20 containment components are required to be tested upon <br /> ❑ NA installation.6 months after,and every 36 months thereafter. <br /> XVI�Mrop tube with mechanical overfill at �3 ❑ Cold start of monitoring panel <br /> XI Drop tube with mechanical overfill ato�3�e El Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Other: see below lZempy4 of b r l <br /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> bail <br /> 4 3v <br /> 6 <br /> 1 <br /> 4212 <br /> is #7 t kn� a- a,&&,W- T6`-0 Wd. <br /> THIS FACILITY IS SUBJECT TO REINSP ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspecr: R ed By: <br /> ( Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 Cj <br />