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oA�'�IN• c <br /> SAN JOAQUIN COUNTY <br /> OENVIRONMENTAL HEALTH DEPARTMENT <br /> N. { 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s4gov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Nam Inspection Date: <br /> C ev ro f'\ v 5� Rpt 8 '-� N o v ?D 012 <br /> Facility Address: Service Request#: <br /> Lf 3 L-I-1+ o d , 5+a c� a SA 0 b q g5 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> M gra s o _7/1Z 013 *' 638-2-35- vi /We*3 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El ❑ mechanical Model: El E) 1 hour hydrostatic 11 Incon TS-STS <br /> 11 electronic Serial#: El Caldwell System 11 Other <br /> 11 line test programmed <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 <br /> ❑ <br /> El positive shutdown Model: ElPrima ps piping testing at: <br /> El fail safe Serial#: p <br /> El NA minutes <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 /> rl:] Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate X This UST facility is NOT APPROVED to operate <br /> 0 St ry i- I Cc{ <br /> I'V�D�Y�I �t1Gt a/ - cc►'-�P� �� D 2/ 20/Z <br /> L <br /> O t' lea <br /> fZLP- <br /> PLL e 6 4604k X1,1. r o <br /> SPSg�' e✓ , <br /> THIS FACIL Y IS SUBJECT TO REINSP CTION AT ANY IME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp tor: Received By: r Title: <br /> �^ / <br /> EHD 23-04 JeYV/Ge Q►�(GM .�/s G�'M� W/f- C S,T,SERRYICEINSPECTION REPORT <br /> RQUES <br /> Rev 4/30/12 dPi(rl rj�� T CUN % /i►�W /�,�n �y /IJG jC . <br />