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oAQutN c <br /> ?••'—+�'••o� SAN.IOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Q: . <br /> y _ 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sogov.org/ehd <br /> q<<FOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> "RlbfRV10dA <br /> Facility Address: Servi Request#: <br /> ISCA2 SCz LvqS <br /> Onsite Service Technician'sName: ICC Service echnician/Installer Exp.Date: .,(Manufacturer Trainin <br /> SERVICE SERVICE <br /> 931 Leak detector `M'1 Spill bucket ❑ minimum 5 gallon <br /> ❑mechanical Model: ❑ El1 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: �� `"'�T U ❑ ❑ 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 Ne`'' <br /> ❑ NA <br /> sensor Secondary containment testinor'. <br /> E] ❑ positive shutdown Model: tAI ao?. 1 ) $1141 Sit Piping <br /> ❑ fail safe Serial#: Sump(s) _UST(s) <br /> ❑ NA -4aNk I '3,4' 4 .�ANrkJW Tj=`2-TS s Manly <br /> sensor Testin-fdr theme components are next du�by: <br /> E] ❑ positive shutdown Model: 11 <br /> ea e a r t n aihment do p ents are required to be tested upon <br /> ❑ fail safe Serial#: Note., <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 <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> 0 46 L c *N C,l 2 �f g� Q�DJU <br /> SI i V Ct '14A <br /> N�e�dLV S a s,T4 7, A q1LID 01,4 <br /> Pte- 'ecl►CON &W Lk r.� <br /> ti , A6 IlNt Klv�- Krdk/ <br /> HI ILITY IS§UBJECT TO REIN PECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In ctor. Received By: T <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />