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Fax Server 9/5/2014 3:44 :51 PM PAGE 4/008 Fax Server <br /> RECEIVE . <br /> SAN JOAQUIN COUNTY SEP 052014 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> Y 1868 East Hazelton Avenue,Stockton,CA 95205 6232 ENVIRONMENTAL <br /> ' relephone.(209)468-3420 Fax-'(209)460.3433 Web:www. . ehd <br /> � HPAtrt-+neo <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fac'lity Name: Inspection D : <br /> Vel f` Gt 24 w <br /> FaclUty Address: Service Req : <br /> Onsite Service Technicien's Name: CC servicd TechnielaMnsts ler Exp.Date: Manufactur Training: <br /> ? � i iia v tvt r . 13 I t� V�: �•�.-1 <br /> SERVICE SERVICE <br /> I LA Leak detector _LLL Spill bucket EYminlmurrl 5 gallon <br /> mechanical Model: 1�r-1 hour hydrostatic 0.Incon T"TS <br /> ©electronic Serial#: f-X7?it.1Ol•I• p Caldwell System CYOther C�-ct1- <br /> 0 line test programmed <br /> -i"Z Leak detectorSpill bucket ❑minimum 5 gallon <br /> [Kmechanical Model: �1 R O ❑ p 1 hour hydrostatic ❑Incon TS-STS <br /> ❑electronic Serial#: D Caldwell System ❑Other <br /> 0 line test programmed <br /> sensor Pricey piping testing <br /> ❑ ❑positive shutdown Model: psi <br /> ❑Fail safe Serial minutes <br /> ❑NA <br /> sensor Secondary containment iesting for. <br /> ❑ ❑positive shutdown Model. UDC(s) Piping <br /> 11 fail safe Serial M Sumps) UST(s) <br /> ❑NA <br /> sensor -Testing for the above co(nponents are next due by: <br /> EI positive shutdown Model: <br /> ❑ D fail sate Serial#: <br /> Note:Pleaso ea ermre u+at 2'cCWMahaetgm eonponerds are rsqurted to ea tasted wPm <br /> ..T- NA irtslmle"s mw%ft sfler,and eve? montl,s IhW*6I ar. <br /> ❑ iJ Drop tube with mechanical overfill at 95% D Cold start of monitoring Fanei <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other:see below <br /> Thls UST facility is APPROVED to operate ❑ This UST facility Is NO r APPROVED to operate <br /> Y <br /> cc1 3 <br /> wig LU P -- <br /> '� r H C.G� Kau h <br /> f <br /> j 5 11 ` etl — a� <br /> .1, k >` VtO .` � +s4c <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHIYS CURB NT HOURLY RATE. "J J'� Ory. <br /> EHD Inspect Regg' ed By . T <br /> U SERVICE REQUEST INSPECTION REPORT;j <br /> EHD 23.04 <br /> Rev 4rWn2 <br />