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�oAqu I!y c <br /> 0, SAN JOAQUIN COUNTY <br /> w. ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> a� Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.s*gov.org/ehd <br /> \tFOR% <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> AR C 0 AM PM 4S 33 33 5-1191-20 )1, <br /> Facility Address: Service Request ir <br /> SS-0 W. Va 1 p ,c Q Road) S R 00 '74S)03 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Jose k 3itrt koldll <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> F-1 ❑ mechanical Model: El 1 hour hydrostatic. ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed El Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model:❑ El psi❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive 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 21 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 /> Z This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> s,te- Ver, - •+ f Cid .5kkllf. <br /> o Alill Pii' 5rlvvQ r 1 re ;ev - V i ej r r , <br /> { Llvo r' L 34 ,. y) 3ervc' <br /> 3 -lot ,I <br /> :i l 1� r �� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY IME AT EHD'S CURRENT HOURLY ATE. <br /> EHD Inspector: Received By: Title'" <br /> Vi • �w � << <br /> EHD23-04 r� bV �Tee-h 111 �09CL�Eb ESTINSPECTIONR T <br /> Rev 4/30/12 <br />