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AQuiN • <br /> • SAN JDAQUIN COUNTY <br /> Q: z� ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.s�.org/ehd <br /> ��/PORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> EM-11s �Voj M&v+ 1016111 <br /> Facility Address: Service Request M <br /> 1"S CPoAF-CiZil A-VC- l5W-*t-01' 5X0062-601 <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Exp.Date: Manufacturer Training: <br /> ni <br /> I—Lr✓•Lt GU 1 937-30q(. 1111113 1/9— 9-3-75f-3 017,1111L <br /> SERVICE SERVICE <br /> _ Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic [I Incon TS-STS <br /> LI electronic Serial#: ❑ Caldwell System ❑ Other <br /> EI line test programmed <br /> _ Leak detector Spill bucket El minimum 5 gallon <br /> El mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El —psi <br /> 11 fail safe Serial #: minutes <br /> ❑ NA <br /> 1.4 Ori sensor Secondary containment testing for: <br /> JR positive shutdown Model: 794- 3y0 — 420 UDC(s) Piping <br /> Wail safe Serial#: -767-11 Sumps) UST(s) <br /> ❑ NA ❑ <br /> sensor Testing for the above components are next due by: <br /> ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: NotePlease be aware that 2°containment components are required to be lasted 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 /> ® This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Vyi L I <br /> r�lt r �l <br /> THIS FACILITY IS SUBJECT TO REINSPECTION T ANY AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: , / Rec d Title: <br /> N.2'( <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />