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oPGL <br /> UtN c SAN JOAQUIN COUNTY <br /> • .G <br /> ��FlWhoA ENVIRONMENTAL HEALTH DEPARTMENT <br /> N . >� . 1868 East Hazelton Avenue , Stockton , CA 95205-6232 <br /> ' • - = ' - <br /> Telephone: (209 ) 468- 3420 Fax: (209) 468 -3433 Web: www . segov . org/ehd <br /> `Q <br /> A � ISOR� <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name : inspection ate : <br /> +ce � (n m � <br /> ev - -f 2 2 2q- <br /> Facility Address: Service Request #: <br /> Cho 1 . � t 1 -� t'1� �e�� L►�1 Ind i sW C � � & <br /> Onsite Service Technician 's Name : ICC Servicejechnician/Installer Exp. Date: Manufacturer Training : <br /> �' VS�IOI 21 2 Dew <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model : Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial : ElEl1 hour hydrostatic ElIncon TS- STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model : Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial : ElEl1 hour hydrostatic ElIncon TS- STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor Primary piping testing at : <br /> ❑ ❑ positive shutdown Model : ❑ psi <br /> ❑ fail safe Serial # : minutes <br /> ❑ NA <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 : <br /> ❑ fall safe Serial # : Note: Please be aware that 2° containment components are required to be tested upon <br /> ❑ NA installation, 6 months after, and every 36 months thereafter. <br /> -� rop tube with mechanical overfill at 95 % ❑ Cold start of monitoring panel <br /> l D5 <br /> LL Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention ( see LG letter 150- 1 ) ❑ Other : see below <br /> 8 �'frt�UST�fa�cttRy is-AP4440VZD4G operate 8 This- UST facility is NOT APPROVED to operate <br /> v ri ► appez sur �- I - 2 <br /> a r b o V <br /> q1 11 <br /> , S <br /> Ao it <br /> Iok <br /> S ioaj &fto Lk rL)v 6 ct� <br /> Vx <br /> r� <br /> C) 0 6t ow QP Wr. <br /> THIS FACILITY IS SUBJECT TO REINSPECTI N AT ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD Insp ctor: Rocoiu "r, Title : <br /> vUA 'Yta.a <br /> EHD 23-04 / 401 (Pi )04 5 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />