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'o.QCgL p <br /> �'•o SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N.®IY 1868 East Hazelton Avenue, Stockton, CA 95205-b232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sl og v.org/ehd <br /> �<<F ORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> 1 re0 S'Mfi)0-0 -#-&C) (D 2tivlo <br /> Facility Address: „// Service Request#: <br /> /-7/ 1 E OS irM/ I-C AV e , d Q r f rCgl SRD0(G&13�(- <br /> Onsite Service_Te ician's Name: ICCrvice Technici staller Exp.Date: Manufacturer Training: <br /> C �2- a II I � Vrr. . �C. Ii �+�I�+ WIX. <br /> SERVICE SERVICE <br /> Leak detector2 t£” <br /> mechanical Model: V2 t�L•-�-b %� Sp tl bucket �'yninimum 5 gallon <br /> 0 ecnic Serial: ,`1 11 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: LIDC(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 /> ❑ fa i I 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 /> O GtJQJ4 �� <br /> F G f5h1k - <br /> z7 GG' <br /> Q, L <br /> YIS r E'l2 <br /> Aw- C, c' <br /> THIS FAC TTY IS SUBJECT TO REINSP TION N IME , T S CURRENT HOURLY RATE. <br /> EHD Inspector: R iv d Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br /> . pua - �oap�Ujork_7�DfGle cwt <br /> i1? -oaf r�u_Q s, ry�c�✓iifon <br /> rlaA, t0_,-7k_?,6) f rM fvrYn C, and <br /> ,..Mope o wt' <br />