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o.A4�IN••.c <br /> 3:�s •.off SAN JDAL'lUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> r Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> Cf'aCi F O'M1�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Aja-�eh,a <br /> lo -IT-11 <br /> Facility Address: I Service Request#: <br /> ysr <br /> Onsite Service Technician's Name: ICC Service Techniciantinstaller Exp.Date: Manufacturer Training: <br /> Ru.�Q —S Iii 3 <br /> SERVICE SERVICE <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> El ❑ electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ 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 /> ❑ fall safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ElElpositive 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 /> ❑ fall safe Serial#: Note: Please be aware that r 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 /> ctrft r <br /> --j <br /> � 1I '7r(nr n D i.�ri C� b.rrJ( /rM �.t. <br /> µ ()rX G)De--s t,,+— -�- r.✓'t U�•- OVVL I'UC " <br /> THIt FACT ITY 1S,SUBJECT TO REINSPECTION T ANY TIAAEAT HD'S CURRENT HOU LY RATE, I S <br /> EHD Ins d Receiv By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />