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oR4utN c \/ SAN JOAQUIN COUNTY N./ <br /> e` ENVIRONMENTAL HEALTH DEPARTMENT <br /> w' 600 East Main Street, Stockton, CA 95202-3029 <br /> LI.F..... <br /> P. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orq/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fa 'I Name: Ins ction D te: <br /> `� �, fir. - K-_ <br /> F dity Address: Service Request#: <br /> 1$1 ( $ a��e d. CiI tOS7 "N Ly 1 <br /> O site Service hnician's me: ICC Service Technlciard staller Exp.Date: Manufacturer raining: <br /> SERVICE SERVICE <br /> SERVICE <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> E3 ❑ mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ElOther <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at; <br /> E] ❑ positive shutdown Model: psi ��, bclpnt� <br /> ❑fail safe Serial#: ISCE minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial#: Suni UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: <br /> Note: Pleaseaware that 2°containment components are requiretl to Ee tested upon <br /> ElNA Installation,a=monMa after,ane every a6 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 /> El This UST facility is APPROVED to operate 00 This UST facility is NOT APPROVED to operate <br /> 70 JES'\6X aN U 06 buweA <br /> A"Ie)LICA Ila <br /> Ls 105r& Ol�j A like, <br /> t <br /> 6r4 k l r4,9. <br /> om 7 ` <br /> 5`23 1 oto rItAy. <br /> THI F ITY IS SUBJECT T INSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD InspeGor. Received By: G- Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10106/10 <br />