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O.P�U iN••C <br /> SAN JOAQUIN COUNTY <br /> _ c&i—, Z <br /> Q. A ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> cq<iFoaa�P <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> S�re e — tom q <br /> Facility Address: Service Request#: <br /> 1 I W S - ma,� h re,�� 'MQ e. sn'0 0 <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> -Tp-rrocc ' VR - 10 -H- 1cl <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El El hour hydrostatic ElIncon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1El❑ electronic Serial #: El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor C L-5 23 Primary piping testing at: <br /> j ,positive shutdown Model: <br /> fail safe"(,,,SeA�} erial #: ❑ minutes <br /> ❑ NA Y" <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°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 /> ci �� Srh suit <br /> - <br /> - v ri -t ► ht t C�oc n i�►� d j�l)Soy- ux�.L — a� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe Received Title: <br /> rn� <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />