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T----- -. <br /> op4UrN <br /> >•''-�1FE'••O <br /> SAN JOAQUIN COUNTY <br /> w �'I ENVIRONMENTAL HEALTH DEPARTMENT Is <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> d�fFORtN� .. <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> -A 9 CLos Atilik <br /> Facili Address, �— <br /> Service Request#: <br /> Onsite Service echnician's Name, [cc Servt echniciannnstaller Exp. Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: Primary piping testing at: <br /> L1 fail safe Serial#: ❑ _ psi <br /> ❑ NA minutes <br /> sensor <br /> [J positive shutdown ModelSecondary containment testing for: <br /> : <br /> F1 Elfail safe Serial #: UDC((s)) Piping <br /> Surl UST(s) <br /> LI NA <br /> sensor ElTesting for the above components are next due by: <br /> F1L1positive shutdown Model: <br /> ❑ fail safe Serial #: <br /> ❑ NA Note. Please be aware that 2°containment components are required to be tested upon <br /> 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 /> �Q va r <br /> -t �e RX e <br /> S 1 10 S b� <br /> S �P.t,U OVA <br /> to 4 8-- ;-iiylti�i 01 , IIA <br /> THIS FA LITY IS SUBJECT TO REINSPE ION AT ANY T!)ME AT EHD'S CURR NT HOU L RATE. <br /> EHD Ictor: R iv d By: Talenatkol <br /> : / <br /> El 23-04 <br /> Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT <br />