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'OAq,U l N CO <br /> SAN JOAQUIN COUNTY <br /> c I', <br /> OLNVIRONMENTAL HEALTH DEPARTMEN <br /> W: <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �l Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.si_ og v.ora/ehd <br /> "o <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST <br /> EQUEST I SPECTs® REPORT <br /> Facility Name: (�j�' � ,�I Insp i`on Date: <br /> ✓afkkr" I >" ri 1 ® Z613 <br /> Facility Address: IService Request#: <br /> 6'_Z - c a- S--�oc_ - 6�(� 0 3 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> $-e `� U In C-00 <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 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 /> El positive shutdown Model: ElPrimaps piping testing at: <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) _A Piping <br /> ❑ fail safe Serial#: Sump(s) 1-28 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 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 /> Lq <br /> ce, ve —� CLl m:-MS. 3m <br /> re s�l� u � �� � a cir/• <br /> Node., ve Q .ulc u b kr Cu ; �- ,o cki cP4 knk <br /> HIS FACILITY IS SUBJECT TO REINSPE NAT ANY/fIMfi ANY/IAT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: i y: Title: <br /> Tec <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 c:j <br />