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0 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org�ehd <br />UNDERGROUND STORAGE TANK <br />Facility Name <br />i.\4� 47� '�"r L.) UK— <br />Facility Addl-ess: <br />lCbll� T)L)c- t Crdlov(_ En <br />Onsite Service Technician's Name: ICC Service <br />war er � <br />PROGRAM SERV IUL <br />�h5& <br />nllnstaller Certification #: <br />SERVICE <br />COh <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />`rn <br />❑ line test programmed <br />❑ <br />Leak detector <br />y: <br />❑ mechanical Model: <br />© <br />❑ electronic Serial #: <br />❑ <br />❑ line test programmed <br />Leak detector <br />❑ mechanical Model: <br />❑ <br />❑ electronic Serial #: <br />❑ line test programmed <br />sensor <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ NA <br />sensor <br />❑ positive shutdown Model: <br />❑ <br />❑ fail safe Serial #: <br />❑ <br />❑ NA <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Drop tube with mechanical overfill at 95% <br />❑ <br />Overfill prevention (see LG letter 150-1) <br />QULNI IiNNrEL:IIVIN KLrvKI <br />Inspection ate: <br />1 1L'6--� <br />Service Request #: <br />���zyv 5-�7l C/-? <br />Manufacturer Training: <br />SERVICE <br />COh <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />Q9 A/4, 1,1 <br />❑ Caldwell System ❑ Other <br />`rn <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />y: <br />❑ Caldwell System ❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ <br />❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other C , r <br />n lw <br />❑ <br />Primary piping testing at: '?/c <br />psi a <br />minutes <br />b�t <br />Secondary piping testing at: <br />I�;z% s' 3.?f <br />psi <br />minutes <br />Secondary cot n�tjnAt repairs or:rEe k/ <br />UDC(s) Piping <br />of L Sump(s) UST(s) <br />Cold start of monitoring panel <br />❑ <br />Corrosion protection <br />❑ <br />Other: see below <br />t r'(.. <br />COh <br />re /1 W��1S d/L �i`cam <br />C-0 24 <br />3 U M 7 ►v e <br />Q9 A/4, 1,1 <br />r ►iku ��a <br />`rn <br />l �r 1 4+ <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspecto : <br />y: <br />Title: <br />F <br />EHD 23-04 <br />/`n <br />vtt <br />