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09/29/2014 12:56 MANTECA CRUISE"'- <br /> PAGE 01/01 <br /> FF' 'FED <br /> Y041% <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 0 C T 01 2014 <br /> Telephone:(209) 468-3420 Fax.(209) 468-3433 Web:wvvw.sioov.org/ehd <br /> ENV1R0N1A-'"7' <br /> �:��. %�4 L HEALTH <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION RWRT <br /> Facility Name: inspection Date: <br /> of�ck�,er ,-, - CI 1q-j - <br /> racility Addresa- 4l Service Request <br /> o <br /> Onsite Service Technician's Name* ICC Service TechnicishAnstaller Exp.Date: Manufacturer Training: <br /> C-T( eA V P_GEC, <br /> SERVICE SERVICE <br /> Leak detector Spill bucket © minimum 5 gallon <br /> ❑ 0 mechanical Model. 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#; <br /> 0 line test programmed C3 Caldwell System >b <br /> Leak detector —Spill bucket 0 minimum 5 gallon <br /> El 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 programmed <br /> sensor Primary piping testing at: <br /> L1 0 positive shutdown Model: El psi <br /> 0 fall safe Serial#: minutes <br /> 0 NA <br /> sensor Secondary containment testing for: <br /> F1 0 positive shutdown Model: UDC(s) Piping <br /> 0 tail sate Serial Sump(s) UST(s) <br /> El NA . sensor Testing for the above components are next due by: <br /> FI 0 positive shutdown Model: <br /> D fail sate Serial#: Note: P'easo Do tware th3t 2°CAnminmvnt wmpanenis are mqvimd to be tastes upon <br /> 0 NA pstsibifion,&mdrlhs akar,and­y 36 months thereat w. <br /> ❑ —Drop tube with mechanical overfill at 95% 0 Cold start of monitoring panel <br /> —Drop tube with mechanical overfill at 95% C3 Corrosion protection <br /> L El Overfill prevention (see LG letter 150-1) [1 Other: see below <br /> This UST facility is APPROVED to operate L-3 This UST facility is NOT APPROVED to operate <br /> lot,, P <br /> 0 ose \/(Z- 4to u 41st(t iro 1C O.LA <br /> A 1bo CA(P-A v-, "'Jak, \1 Q <br /> e C)V\.- <br /> c <br /> oa I <br /> 21A 0 <br /> Q _(Q!21k aa <br /> TH116 FAGILITY 15 SUBJECT TO RE NSPIECTION AT ANY TAT EME)'S CURB NT HOURLY RATE. <br /> EHD Inspectpr Received l3y:, <br /> n L_2 <br /> L <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPDR- <br /> Rev 413W12 <br />