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oPqulN.- <br /> SAN JOAQUIN COUNTY <br /> � { ENVIRONMENTAL HEALTH DEPARTMENT <br /> : 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c•. _. .. Telephone:(209) 468-3420 Fax.(209) 468-3433 Web:www. <br /> sioov.arp/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE <br /> REQUEST INSPECTION REPORT <br /> Facility Name: <br /> K90 � C�� n 1 ! f Inspection Date: <br /> Facility Address: <br /> 1 if r /� 5 r� —1s Service Request#: <br /> Onsite Service Technician's Name: 1CC Service Technician/Installer Exp.pate: manufacturer Training: <br /> Q <br /> ��rv�,s Nt a© r� 5,-75w! �L N C©N <br /> Lu1TC 51231 <br /> SERVICE tL <br /> Leak detector SERVICE <br /> ❑ ❑ mechanical Model: Spill bucket <br /> electronic Serial #: El El hour hydrostatic ❑ minimum 5 gallon <br /> ❑ line test pro rammed y ❑ Incon TS-STS <br /> ❑ Caldwell System 11 Other <br /> Leak detector <br /> ❑ ❑ mechanical Model: 3 �}- ` <br /> El electronic �{ ❑ minimum 5 gallon <br /> Serial #: Imo. ❑ i hour hydrostatic X Incon TS-STS <br /> ❑ line test procyammed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: <br /> Primary piping testing at: <br /> ❑ fail safe Serial #: ❑ psi <br /> ❑ NA <br /> - sensor <br /> minutes <br /> ❑ ❑ positive shutdown Model: Secondary containment testing for: <br /> ❑ fail safe Serial #: UDC(s) <br /> ❑ NA Sump(s) Piping <br /> ❑ UST(s) <br /> sensor <br /> ❑ positive shutdown Model: Testing for the above components are next due by: <br /> ❑ <br /> ❑ fail safe Serial #: <br /> ❑ NA. Notes Please be aware that 2°containment components are required to be tested upon <br /> ❑ Drop tube with mechanical overfill at 95% installation,6 months after,and every 36 months thereafter. <br /> ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Corrosion protection <br /> Other: see below <br /> ❑ This UST facility is APPROVED to operate (� <br /> This UST facility is NOT APPROVED to operate <br /> Vj <br /> !►1 S �� r" vJ 4'. 0>,1 i <br /> L ff ` <br /> �j i t 1.9") jy <br /> " <br /> r <br /> I-l1P i P0 <br /> � /10 r <br /> 1 1111 11, <br /> u r res <br /> LCC w i D Cl 6r e'l qs <br /> THIS FACILIT IS SUBJECT TO REINSPIcCTI AT AY TIM END'S CURRENT URLY RATE. <br /> EHD Ins ecto . <br /> 1 a 4c, � Re eived 8 Title: <br />.HD 23- [/�J <br /> Rev 413 2 UST SERVICE REQUEST INSPECTION REPORT <br />