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AqutN. _ SAN JOAQUIN COUNTY <br /> e a •ENVIRONMENTAL HEALTH DEPARTMENO <br /> y=k,: 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Li <br /> eq�i F iiR`'�P <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sogov.orq/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Af�z WPM -j4_ S7"& 10,46 --U Ii 2_� <br /> Facility Address: Service Request#: <br /> 20 low ft6 par4y&q 00&44�l 9- 006984 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> 3a 1400, !�Aj4jAQJZ, VM L <br /> SERVICE SERVICE <br /> Leak detector <br /> 1� ❑ mechanical Model: -MLO Spill bucket 11 minimum 5 gallon <br /> electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ <br /> ❑ line test ro rammed Caldwell System ❑ Other <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 Rrogrammed <br /> KT-WWr j4hsor <br /> ❑ positive shutdown Model ' �a ��; Primary piping testing at: <br /> El psi <br /> 11 fail safe Serial#: 2 <br /> ❑ NA minutes <br /> RIT sor Secondary containment testing for: <br /> v ❑ po itive shutdown Model:\JP- 4-1W 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 2°containment components are required to be tested upon <br /> ❑ NA installation,6 months after,and every 36 months thereafter. <br /> ❑ j 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 /> f This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> I <br /> I <br /> F <br /> \ P 1A IAD- ./J <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT E D'S CURRENT HOURLY RATE. <br /> EHD I e or: I Receiv y: Title;- <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />