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O.PI•U I ,N <br /> ? ' _� SAN JOAQUIN COUNTY <br /> 'Two 9 � r .took y ENVIRONMENTAL HEALTH DEPARTMENT <br /> N . _ 1868 East Hazelton Avenue , Stockton , CA 95205 - 6232 <br /> notTelephone: (209 ) 468 - 3420 Fax: (209) 468 -3433 Web: www . sigov . orq/ehd <br /> cq i F o'ac'�P <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT' <br /> Facility Name : Inspection Date : <br /> ye) b Aia L C;W9 <br /> Facility Address : Service Request # : 69 g C61 10 <br /> MOO, j1" . CCS G C . <br /> Onsite Service Technician 's Name : ICC Service Techni a /Installer Exp. Date : Manufacturer Training : <br /> 1 r1 � drolo, <br /> 11P�' C N <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial : ❑ El hour hydrostatic [I Incon T& STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> 11 mechanical Model : Spill bucket Ell minimum 5 gallon <br /> L1 ❑ electronic Serial : ElEl1 hour hydrostatic ElIncon TS -STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> El <br /> shutdown Model : Primary piping testing at : <br /> fail safe Serial # : El psi <br /> El El <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 /> ElElpositive shutdown Model : <br /> ❑ fall 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 /> — 5 14 � <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> onon TeX va SMAW <br /> i 1Yto LkO GUQUQ f r U OD S . <br /> 1!'k ctcw W, CLOG V4W IQU 20 D3 <br /> , I <br /> j 2 l Q <br /> h t s, = 0 P W evA ondpy <br /> U 1101 WL 15aw ever M on � f etc < c �r ,a to <br /> THIS FACILITY IS SUBJECT TOR NSPECTION A ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD Inspect R eived B Title : <br /> V1 Ct, VVA <br /> EHD 23-04 1 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 I q d/•//Ij�' <br />