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pR,g4�l�j, O <br /> �:'- ''•OO <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> X <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax.(209)468-P433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: [pJ /f}I/A/ {i{ Ins[fp+J�Jection Dalte:6i )] <br /> rl PAI <br /> A 1- <br /> Facility Address• Service Request#: (ff!} <br /> 7 bV-A <br /> Onsite Service Technician's Name: ICC Service Technicianfinstaller Exp.Date: Manufacturer Training: <br /> zcf )ST <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> El ❑ electronic Serial#: ❑ D 1 hour hydrostatic ❑ Incon TS-STS <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 programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑fail safe Serial#: minutes <br /> ❑ NA <br /> sensor ; Secondary containment testing for. <br /> ® ❑ positive shutdown Model: :5 ct UDC(s) Piping <br /> ❑fail safe Serial#: i Sump(s) UST(s) <br /> ❑ NA ' <br /> sensor Testing for the above components are next due by: <br /> ElElpositive shutdown Madel: <br /> ❑fail Safe Serial#: Note: Please be aware that 2°containnxnt componerds are required to be tested upon <br /> E] NA instailattom 6 morins 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 /> I Alr�(; a� }.f °..( 0>( i ko (; fill 0 <br /> /t i fCt <br /> `� '� :% ;l AI! X(T t o (°; (_;w1 w� r % 1• �k`+ ' � C '��l l��� <br /> t,.i ,f1i0.J', 0 '7l t1te. , •_ it t e `�J � c 1 <br /> i <br /> fA <br /> i IS-t s yy 4' ! l(•I C4.1 + ,(` _> i.� ;tit ti', .t / ;I :il t,` I 1) <br /> THIS FACILITY IS SUBJECT TO REINSPE TION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHQ•14 or: Recely <br /> r . Title:3 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4134!12 > <br />