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09/29/2014 12:56 2098"42683 MANTECA CRUIS--- PAGE 01/01 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/ehd <br /> 7 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facillty Name: inspection Date: <br /> o -t,ee . ( <br /> Iq-j 01 <br /> racility Addresa- Service Request <br /> 'Md 0::�4 o(4 -7 <br /> ,n-Rtrob I f.- C, <br /> Onsite Service Technician's Name, -12C Service Techniclanllnstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> C3 0 mechanical Model: 1)6 71-1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: C <br /> 0 line test programmed 0 Caldwell System Othe C��r� va.(U<- <br /> ----Leak detector —Spill bucket 0 minimum 5 gallon <br /> ❑ 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial# 0 Caldwell System 0 Other <br /> 0 line test Mrammed <br /> sensor Primary piping testing at. <br /> 0 0 positive shutdown Model: El psi <br /> 0 fall safe Serial r17 <br /> V <br /> 0 NA D- <br /> minutes <br /> fl, 0 - <br /> .T <br /> sensor Secondaryconta rTibFf*feStingfor- <br /> r-1 0 positive shutdown Model; UDC(S) „Piping <br /> 0 tail safe Serial#: Sump(s) -07T t 5 201t 1ST(s) <br /> 0 NA <br /> sensor El Testing for the above comonn ar9L <br /> n. <br /> H <br /> 0 0 positive shutdown Model: <br /> N T <br /> 0 fail safe Serial#: Note! F'sa”too aware that 21 pontainrnvnM4 to bo tested upon <br /> 0 NA ywallsfion.6 months after,and every 34 months theteatt#t. <br /> ❑ —Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> —Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to operate 0 This UST facility is NOT APPROVED to operate <br /> V1 C', s �to uk ( k1 U� o f3�4i C -�e. <br /> P A(W 610CA(P—A xi,6 \Zj-k\jQ <br /> k S -- e nvt- 'v 6-i .:j -4v-alrkvl.-,Aa�k Pfd,, C)i,p.- <br /> "'n a t,,l a.GA4 (".0 Vo uc_ ii O)r.( wa,", f <br /> 0 <br /> THIld FAGILITY 15 SUBJECT TO RE NSFECTION AT ANY TAT EtiD*S CURRENT HOURLY RATE, <br /> EHD InspectpK— Received By;, Tide- <br /> L <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPOK <br /> Rev 413W12 <br />