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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 , siqov . org /ehd <br /> . ., QPM P <br /> Tele <br /> •C / FOR / <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : j Inspection Date : <br /> 4 `10 ssssss C9 <br /> La r7.0 <br /> Facility Address : Service Request # : <br /> c�-13 Mo. I os0 . S12QA:�fQ a (0 <br /> Onsite Service Technicia s Name : ICC Service Technician/Installer xp . Date : Manufacturer Training : <br /> -- so fit- (OPW _ <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical, Model : ❑ 1111 hour hydrostatic ❑ Incon TS - STS <br /> ❑ electronic Serial # : ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <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 /> 7 ❑ positive shutdown Model : ❑ p <br /> si <br /> ❑ fail safe Serial # : <br /> 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 /> 4 � Drop tube with mechanical overfill at 95 % ❑ Cold start of monitoring panel <br /> 1 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 /> `J QA C c s p oCjiD " C, <br /> Ck <br /> � w 00 <br /> Q Qe, C3i 0 d.�o� <br /> 1� <br /> re cv� 5TOCCtA 24 <br /> � Q <br /> MVj.0Av0A lro~ VQ4 xo—, V h 09 \ss)c Ok. k, <br /> THIS FACILITY IS SUBJECT TO REINSPE ION AT ANY TIME AT D ' S CURRENT HOURLY RATE . <br /> EHD In ector: Re ed By : Title : <br /> l r t <br /> EHD 23-04 ` r„( � _l ✓� 1 .�� ✓� �Q �, /�� n � � 491 tU,jST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/ 12 CS✓v tA p_a` ,C1,� Q A K466 i 49 (� � 'lq tok f p � z' t*46 `/ 7 " <br /> L .. J <br />