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Op'QUtly C <br /> .c1 <br /> �,•• __�_r_• •,��� SAN JOAQUIN COUNTY <br /> -� ENVIRONMENTAL HEALTH DEPARTMENT <br /> ll 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> \� Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Atli L Sew C::,- a-o-40rg <br /> Facility Address: Service Request#: <br /> LA <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: 0.(O-V o <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ <br /> El electronic Serial #: A 111 hour hydrostatic ElIncon TS-STS <br /> El Caldwell System XOther C.©vyOS( <br /> El line test programmed r) <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ <br /> El mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> El electronic Serial#: El Caldwell System El Other <br /> ❑ line test programmed <br /> sensor Prlmt ary piping testing at: <br /> El positive shutdown Model: <br /> ❑ El -�-�- <br /> fail safe Serial #: psi nt,+z CO"\jQAe� <br /> ❑ NA LC minutes 0 <br /> sensor Secondary containment testing for: '1 <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: <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 SQ <br /> Lu <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> C1110 Je_ <br /> L o r (W-A, e- SQiJ -n . e_ 1 <br /> t V Ct.d f- �0. <br /> It 6CA <br /> THIS FACILITY IS SUBJE T TO REINSPECTION AT A Y TIME AT EHD'S CURRENT HOU Y RATE. <br /> EHD Ins r: Received Titl <br /> EHD 23UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4!30110/12 ` fj <br />