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''.. SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN I <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orglehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facial me. Inspection Date: <br /> — Aozom <II4rJ i -�-1 I <br /> Facility,Address, A4Service$equest q: <br /> Ons service Technician's Name: ICC Service Technic nstaller Exp.Date: Man facturer Training: ! ^ <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ ]neon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System 0 Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ 111 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: El Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: _ ❑ psi <br /> El fail safe Serial#: . _..__-- minutes <br /> ❑ NA <br /> sensor Secondary containment testis for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> © fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor � Testing for the ab ve components are next due by, <br /> ❑ <br /> El positive shutdown Model: At iri <br /> ❑ fail safe Serial# / Note; Pse leabe wafe that 2°contalnr a cmwonerft we to be WW UP00 <br /> ❑ NA tristallatbrl 8 wnihs eller,end every 38 monlha(hereafter. <br /> Q 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 /> t 1 X41 v N-C 10k <br /> I <br /> ^ '� N'Cpti <br /> p� woyt <br /> THIS FAG LITY lS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector. + , R9ce[v Title: <br /> EHO 23-04 UST SERVICE REQUEST INSPECTION REP, <br /> Rev 10108/10 <br />