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O.p4UiN' C <br /> ?:—+6�`•P�, SAN aJOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> wt. '`i 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> q�lF�,pP�ii <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility : Inspection Date: <br /> W �on rood Mart 111ay lao 15 <br /> Facility Address: Service Request#: <br /> 43 (S E• �J�'1' 10o R� S b(,x Sf-oo-78-794, <br /> Onsite Service Technician's Name: ICC Service Tt�chnicia�NIRV al�ler�gyp.Qate: Manufacturer Training: <br /> is q,rcQ E - M i Sa4II4 GP�t�- d �t (t�.t) 1✓llP- <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> El ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El 11 electronic Serial #: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fall 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 2-contalnment components are required to be tested upon <br /> ❑ NA Installaton.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�p I Sit �?J <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> on <br /> 1 t L I^6w A [A l�p LT SO) ' cI ell <br /> 1 e k a MM 2(4e tesi VC . OA 0,P fDf l <br /> wk) -to,(45Q SAA fd-)C r I — 3 <br /> - I 4g n ink II B 3 $• If <br /> R7 Big <br /> THIS FACILITY IS SUBJECT TO REINSPE ION AjT ANY TIM AT EHD'S CURRENT HOURLY RATE. <br /> EHD ctor: M Rece' a By: Titl <br /> EHD 23-04 ' UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130/12 /a <br />