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OPpUI C <br /> �.•'�.�GE'•.O <br /> _:• __�_,_ � SAN JOAOUIN COUNTY <br /> ar -+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Cq<,F:O Ra�P <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s'gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility N e: Inspection Date: <br /> T _ljcm -1 )11�; ;LC <br /> Facility Address: Service Request#: <br /> �1c . 111a, Vat WCLLA( ,cam .-SP- c u <br /> F06—nsKite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> r�ra v,(2 z t v)tiJ - CSI-- I <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket minimum 5 gallon <br /> El El hour hydrostatic Incon TS-STS <br /> El electronic Serial #: <br /> El line test programmed �❑ Caldwell System Other drn <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: [] psi <br /> El fail safe Serial #: - <br /> El NA minutes <br /> sensor Secondary containment testing for: <br /> El El positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA El 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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe R y: Title: <br /> J - <br /> � EDO r'l,_0 h4 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />