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O Quf ,N. ,.0 <br /> ?' ' *to <br /> � SAN JOAQUIN COUNTY <br /> *to <br /> r~ ENVIRONMENTAL HEALTH DEPARTMENT <br /> I� E { 1868 East Hazelton Avenue Stockton , CA 95205 -6232 <br /> Telephone : (209 ) 468 - 3420 Fax: ( 209 ) 468 -3433 Web: www . sigov . org /ehd <br /> � jKOR <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : Inspection Date : <br /> &moo- n 0 - -10l <br /> Facility Address : Service Request # : <br /> c� b �cQM nol sRqLAcA JTL W14 CP <br /> Onsite Service Technician 's Na e : ICC Service echnician/installer Ekrfl. Date : Manufacturer Training : <br /> vao J Six IZ ,� c7L101 alb <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model : Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> 1:1 mechanical Model : Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial # : ❑ ❑ 1 hour hydrostatic ❑ Incon TS - STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> El shutdown Model : El psi piping testing at : <br /> ❑ <br /> El fail safe Serial # : p <br /> ❑ NA minutes <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 : \1PH :) ULoulp ( We — P C7CjO 4i) L 6(i . tk 1 <br /> ❑ fail safe Serial # : Note, Please be aware that 20 containment 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 <br /> This UST acility is APPROVED to operate El This UST facility is NOT APPROVED to operate <br /> V <br /> ohSi osety r s L&pot. <br /> tl�►'Y�'t� Y O X S I Q e 3 8St?XV s L <br /> MooxwV�Gb -E-i ak. +eA&i 2 &,kni <br /> odd <br /> 0 v\ Q.Xi s i W" i Vt,� QJrS a.Q (� ea- <br /> rQ4 rqrQ__- At/tic <br /> mmmm3 <br /> At %wor tea r'l <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENt HOURLY RATE . T <br /> EHD InspeV . , Received By: � 40 Title : I / _ /2 <br /> r <br /> EHD 23-04UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 P11 <br /> � o L <br />