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AquIN <br /> S^N JOAQUI COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME <br /> N _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.sogov.org/ehd <br /> q�1 FORS <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> to <br /> Facility Address: Service Request#: <br /> V�Ybl e v„ Rd P" io 6 S & �;), <br /> Onsite Service Technician's Name: ICC Se ici /Installer Exp.Date: Manufacturer Training: <br /> Ar4ro Pexel, 1 -IC2 G a"o 15 -DNcotl - 1 -�- � <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 El positive shutdown Model: ❑ Primaps iping testing at: <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: �,Up ���p[A <br /> ❑ fail safe Serial#: Note: Please be aware that 20 containmen 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 anha I OY, n.5w5 <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> i7 T� +o &e v� r0 S STP S%-L �1 r <br /> 4D 4ez,1&VVIL C&L is4su o .1 A I&lab ;t I <br /> vi eo t\( T -h>- t <br /> aemvzd -1, � . cO- - <br /> e- L,4.0 <br /> Cad wcQ---A C a end 'aA b Iqzgxf <br /> s7a 71. S un S c� <br /> THIS FACILIT IS SUBJECT TO REINSPECTION T ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In tor: Received By: Title: <br /> BTU 0 W-ELfMIJ �2G4�r71 f X <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />