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q,4 - <br /> ' SAN JOAQUIN COUNTY <br /> e 1 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue,Stockton,CA 95205-6232 <br /> -140 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.$jgov.ora//ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspectlo Date:( <br /> Co 0"7 o o31 <br /> Facility Address: Service Request fi: <br /> 800 E - Ke-14It ma,., L, <br /> O Re Service Technician's Name: ICC Service Tac bnicle Ansteller Exp.Date: Manufacturer Training: <br /> Y , UST int a11ch,;, W 1 61L [ <br /> (`1r'C.f I •chi. 03,10-7/1Ufl- ti�i� 1NjlI:C 1-f lei <br /> SERVICE <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑—1hour hydrostatic ❑Incon TS-STS <br /> ❑ electronic Serial#: ❑Caldwell System ❑Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑minimum 5 gallon <br /> El ❑ electronic Serial:: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑positive shutdown Model: El —psi <br /> ❑fail safe Serial#: minutes <br /> ❑NA <br /> sensor <br /> 1 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: <br /> ❑fail safe Serial#: Nota: Pleaaa be aware eW 2'mdakr„aM con pmm w ate mored to be basted upm <br /> ❑ NA wranauon.B mvnlm after,and away 36 manttre ftreaftw. <br /> C� _S-4 Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> Lid -�j1 Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> Overfill prevention(see LG letter 150-1) O Other:see below <br /> This UST facility Is APPROVED to operate O This UST facility Is NOT APPROVED to operate <br /> t/ �. <br /> 0-t. C', .1L I V8, U T <br /> F �.�, Il;t a rQ ta <br /> �,b i st� 5(6 orl 6w& L -4v <br /> G t & 9 h i t��, Q <br /> I o Oln <br /> 4�.►-A S L,4 to <br /> 1 a 11 CCI Ct, S <br /> 0 <br /> THIS FACILITY ISS BJECT Td REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> LEHD I tor. ,ry Received By ` Tufa; <br /> EHD 23-04 'J <br /> UST SERVICE REQUEST INSPECTION REPORT <br /> Rev WW12 <br />