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I.N.,.co <br /> — tE SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.siaov.org/ehd <br /> ORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Ck v =- - � N", <br /> Facility Address:Lf Service Request#: <br /> 3 �- �a �-��_ VY sgoo (Dq Z <br /> Ons Service Tech ician's Name: ir. ICC Service Technician/nstaller Exp.Date: Mana ture7. <br /> ai mg: <br /> 9-94 1151 511!511� 19 <br /> SERVICE SERVICE "Ilk'41 <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 /> ICY Q 5 gallon <br /> ❑ mechanical Model: ❑ minimum <br /> Leak detector <br /> El ;E�,1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System El Other V5 VaL <br /> ❑ line test programmed <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> Elq�. <br /> 0 fail ❑ psi safe <br /> ❑ NA safe Serial #: 41 iA minutes � << <br /> sensor Secondary containment testing fo <br /> ❑ ❑ positive shutdown Model: UDC(s) cl] Piping <br /> ❑fail safe Serial #: Sump(s) gam/ r UST <br /> ❑ NA I <br /> sensor Testing for the above/components are next ue by: <br /> El7� <br /> ❑ positive shutdown Model: r�6r / piOdn s <br /> ❑ fail safe Serial#: Note: Please be aware that 9'containm t corUnents 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 /> Ic z c—r -4c nak 4 $ <br /> t _ <br /> 4- w <br /> /V r - j: qitV_C u 4' <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. - <br /> EHD Inspector: Recei By: Title: <br /> Za <br /> 7q <br /> z tz � <br /> EHD 23-04 L`/��( UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />