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O.PQ U I N••.0 <br /> SAN JOAQUIN COUNTY <br /> CNVIRONMENTAL HEALTH DEPARTMENT <br /> W <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sogov.org/ehd <br /> cq�11:0 P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Cru i er-S $ 15-2013 <br /> Facility Address: Service Request#: <br /> 1134 wt I nov 0, s1z oo 2 <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> 2_ <br /> 4- 11-15 VR - 1,-1 b-1',� <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: ElEl1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System E] Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> F] ❑ electronic Serial:: El El hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System E] Other <br /> sensor <br /> positive shutdown Model: 3 "20g Primary piping testing at: <br /> fail safe Serial #: El Primary <br /> ❑ NA minutes <br /> MAU sensor Secondary containment testing for: <br /> ❑ ❑ positi e 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 /> 5 -c-e� or wov, etd o 8 ' -2o I3 too- <br /> 4 'UQI.t u v g- 1 s X01 <br /> 52P1/1 C)Q ct�41o oak l q 5 bgL2EO C, S y <br /> -T-i rn <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD,Inspector- Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />