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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> X <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> UP 4 1 <br /> �VIZ4 <br /> Facility Address: Service Request#: <br /> \/I'q CIL ` VQ- , --<*-0C", 10 v-,. 5)L co--I q(0 G, f <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> OP()L) — o1—p1 Lo 19 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket Vminimurn 5 gallon <br /> ❑ 0 mechanical Model: Xl—hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System )<Otherd4VL� <br /> 0 line test programmed <br /> Leak detector Spill pill bucket minimum 5 gallon <br /> ❑ mechanical Model: <br /> El electronic Serial#: ] hour hydrostatic 0 Incon TS-STS <br /> 0 line test programmed 0 Caldwell System -A_Other <br /> sensor. Primary piping testing at: <br /> El 0 positive shutdown Model: 1771 psi <br /> 0 fail safe Serial#: minutes <br /> 0 NA <br /> - sensor Secondary containment testing for: <br /> F-1 0 positive shutdown Model: UDC(s) Piping <br /> El fail safe Serial#: Sump(s) gq 1271 UST(s) <br /> El NA <br /> sensor Testing for the above components are next due by: <br /> 1771 0 positive shutdown Model: <br /> 0 fail safe Serial#: <br /> Note: Please be aware that 20 containment components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> Drop tube with mechanical overfill at 95% M Cold start of monitoring panel <br /> Drop tube with mechanical overfill at 95% El Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) El Other: see below <br /> This UST facility is APPROVED to operate El This UST facility is NOT APPROVED to operate <br /> 9 CXt 2 <br /> cop -tupe- vwpj�- rW 4 (34" ( cut " 3/9 CoDioil <br /> In ,0 A\X-8 Oak ed OL�t 4 <br /> 60 Q 1 A Ltd. -)3-4 ct( <br /> 00 1 11 tCIVIS-,JL :tKA 0-1 �QUQAk z— 4a-cj, <br /> 7, q a"g t*6 <br /> THIS FACILITY IS SUBJECT TO REINSPTION AT elNY EHDIS CURRENT HiDdRI Y 67ATE. <br /> PHD Inspector: ce' ed By: r Title: <br /> n <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />