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F" 1 <br /> at'•'Q•Z�,�N <br /> SAN JOAQUIN COUNTY <br /> z 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 /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> QU 'Ik 3+o Ir e I <br /> Facility Address: Service Request#: <br /> 116-3 L 'n e of IVY, L _L11CA 00 / <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Ex ate: Manufacturer Training: <br /> lzf e l I`7 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El 1 hour hydrostatic ❑ Incon TS-STS <br /> 11 electronic Serial#: ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> positive shutdown Model: 19JES 60-:209 ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <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 20 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 /> SI io a aJdq aE i1su L ndva- <br /> juta jo V-a e <br /> THIS FACILITY IS SUBJECT TO REINSPECTION T ANY TIMf AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector. AlaReceive//-/T"j/Z/V)1 ' 1Title- <br /> ar <br /> EHD 23-04 UST SERVICE.REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />