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OPa'U•I N'•.0 <br /> �. +E •o SAN JOAQUIN COUNTY <br /> Q tNVIRONMENTAL HEALTH DEPARTMENT <br /> U0 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> _ Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sugov.org/ehd <br /> Cq�%F p•R�`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fa ty Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> 1-7 11 YoS*Ae, M (A 9S3" Sft& 9 V <br /> Onsite Service T��W <br /> ' me: ICC Service Technician/nstaller Exp.Date: Manufacturer raining: <br /> 1�u 4- "�� 18-I 5 ; o <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucketminimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ <br /> El electronic Serial: K1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> 70W. <br /> ✓ sensori Primary piping testing at: <br /> ❑ positive shutdown Model: 0 C3,4.�V -Z( ❑ psi <br /> ❑ fail safe Serial#: I�q ls' minutes <br /> El NA <br /> ,271 senso Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: 9 Y34d '%7 UDC(s) Piping <br /> ❑ fail safe Serial #: '79 (, 9 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 20 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 /> 2L4MUjW Se <br /> 0`7 g1 <br /> THIS.FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect Received B Title:: - <br /> i <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />