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..... -::.:.. ...... r.:. .... .... I t.Y . . <br /> ECEIVED <br /> SAN JOAQUIN COUNTY <br /> Qj ENVIRONMENTAL HEALTH DEPARTMENT AUG 2 2 2014 <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 <br /> q refephone:(209)468-3420 Fax:(209) 468-3433 Web: s' 11-1o /ehd 11 L <br /> c k. TA EALTH <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUES_ W&iff6Wbff REPORT <br /> Facility Name: Inspection Datp: �d <br /> Facility Address: - , Service Request <br /> C. <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑Incon TS-STS <br /> ❑line test programmed ❑Caldwell System ❑Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑mechanical Model: <br /> ❑electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑Incon TS-STS <br /> ❑line test programmed ❑Caldwell System ❑Other j <br /> sensor Primary piping testing at: I <br /> ❑ ❑positive shutdown Model: El -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: Ptease be aware that 2°containment oomponents are requ+red to be tested upon <br /> ❑ NA installatlon,6 months atter,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 /> 60_ e <br /> rL1r..�:� • .�A�.. a., <br /> THIS f C L'�171Y ISS BJE•(;;T TO REINSPECTION AT ANY TIME AT EHD`S CURRENT HOURLY RATE. <br /> EHD insfSec r: / Received By,__ _,_. ._ Title: e <br /> EHD 23--dor ji UST SERVICE ftE' I S7 INSPEPTION REPORT <br /> Rev 4r <br />