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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Roin Street, Stockton, CA 95202-"3029 <br /> Telephone:(209)468-3420 Fax. (209Y468-3433 Web:www.siQov.ord/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name:. inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Tachniclaifs Name: ICC 1.9rviceTechnlcianllnstaller Exp.Date: Manufacturer Training: <br /> °y erre S"'te 7-'i 4A, <br /> SERVICE SERVICE <br /> Leak detector <br /> 0 mechanical Model: -Spill bucket 0 minimum 5 gallon <br /> ❑ 171 <br /> 0 electronic serial#: 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 Caldwell.System 0 Other <br /> 0 line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El 0 mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System 0 Other <br /> 0 line test p[22rammed <br /> sensor Primary piping testing at: <br /> El 0 positive shutdown Model: El psi <br /> 0 fall safe Serial minutes <br /> 0 NA <br /> sensor Se-condarwcontainment testing for <br /> 0 positive shutdown Model: 57Z6, 7M UDC(s) Piping <br /> El 0 fail safe Serial Sump(s) UST(s) <br /> 0 NA <br /> sensor Testing for the above components are next due by: <br /> ❑ I ) <br /> 0 positive shutdown Model: 70 10 <br /> 0 fail safe Serial#: <br /> W. F41.be aviare that r ormtsment components are required to be tested upon <br /> 0 NA instalWon,6 months after,and every 36 months thereafter. A <br /> ❑ Drop tube with mechanical overfill at 95% 0 Cold start of monitoring panel <br /> El Drop tube with mechanical overfill at 95% 11 Corrosion protection <br /> 11 Overfill prevention(see LG letter 150-1) 11 Other see below <br /> 0 This UST facility is APPROVED to operate El This UST facility is NOT APPROVED to operate <br /> uz�k 64 <br /> 4-7 <br /> 7- <br /> a-S <br /> e <br /> 4��c o,,Anj Ca,4-,Awe--� 6�^V- Li,4t- <br /> THIS FACILITY It SUBJECT TO REINSPECTIPN AT ANY TIME AT EHDIS CURRENT HOURLY RATE. <br /> EHD Ins7111Title: <br /> tie: <br /> ,0141 Zr, <br /> EHO 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06110 <br />