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RQU!(y SAN JOAQUIN COUNTY N ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 �: ;P.. Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd �<hio UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST EQUEST IN SPECTION REPORT Facility Name: A {'00 SERVICE 1AAT Inspection Date: MaktiL Facility Address: V ❑ 1 hour hydrostatic ❑ Incon TS -STS Service Request #: Onsite Service Technician's Najl� a ICC Service Technician/installer Exp. Date: 7609- T �-/�/2 ► Manufacturer Training: � &/ ® 66 6 ' / ❑ This UST facility is APPROVED to operate THIS FACILITY IS SUBJECT TO REINSPECT'. EHD Inspector: Ks r r SERVICE SERVICE 1AAT Spill bucket ❑ minimum 5 gallon eak detector ❑ 1 hour hydrostatic ❑ Incon TS -STS mechanical Model: ❑ Caldwell System ❑ Other ❑ electronic Serial #-. fiL Spill bucket ❑ minimum 5 gallon ❑ line test programmed ❑ 1 hour hydrostatic ❑ Incon TS -STS Leak detector Model, Mo ❑ ❑ mechanical Primary piping testing at: ❑ electronic Serial #: psi ❑ line test programmed minutes sensor Secondary containment testing for: positive shutdown Model: )< fail safe Serial #: i stets Sump(s) LIST(s) ❑ NA sensor ❑ ❑ positive shutdown Model: _�* / � I ;.r ❑ fail safe Serial #: Note: Please be aware that 20 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ NA Cold start of monitoring panel sensor ❑ ❑ positive shutdown Model: Other: see below ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LIS letter 150-1) ❑ This UST facility is APPROVED to operate THIS FACILITY IS SUBJECT TO REINSPECT'. EHD Inspector: Ks r r SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) _ _ Piping Sump(s) LIST(s) Testing for the above components are next due by: _�* / � I ;.r Note: Please be aware that 20 containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. ❑ Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below This UST facility is NOT APPROVED to operate '_. _ 1. .�' / ,-,�• _►tn.w n®. L AT ANY TIME AT EHD'S CURRENT HOURLY RATE. Title: �-- 7�11-;Allwxl'111 //i/. //P El 23-04 ® (J V UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10