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° 0 <br /> 4uly 'Q SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y �Y � 1868 East Hazelton Avenue , Stockton , CA 95205 -6232 <br /> 00 00 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web : www . s * gov. org/ehd <br /> UNDERGROUND STORAGE TANK ( UST ) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date : <br /> A rca 8` 3812 2/ / �p ) g <br /> Facility Address : Service Request #: <br /> s - Esc /� � � , , �787 � � <br /> Onsite Service Technician's Na e: ICC Service Technician/Installer Exp. Date : Manufacturer Training : e <br /> ZCzi'I� JIV/ /; oexe YIl � 21c S 8 s vzrcQe �r , R �f- gM a 9 / <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model : <br /> ❑ El 1 hour hydrostatic [I Incon TS-STS <br /> El electronic Serial # : ❑ <br /> El line test programmed Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model : <br /> ❑ El El hour hydrostatic [I Incon TS- STS <br /> ❑ electronic Serial # : <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> Primary piping testing at : <br /> ❑ ❑ positive shutdown Model : CPd psi <br /> ❑ fail safe Serial #: ;0 minutes �e y � <br /> ❑ NA <br /> sensor Secondary containment testing for : <br /> ❑ ❑ positive shutdown Model : UDC (s) Piping <br /> ❑ fail safe Serial #: Sump (s ) UST(s ) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by : <br /> ❑ ❑ positive shutdown Model : <br /> ❑ fail safe Serial #: Note: Please be aware that 20 containment components are required to be tested 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 /> El Overfill prevention (see LG letter 150- 1 ) Other: see below Vji'WAfl4- j?(jM &VJIUL 7�Vj <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> UUt t° SS C V ptrl 'i' Clc -f t7 G VQ C� �(�/L Co rvtrn u.�1,��ca1b ►7 V1 i' Pi n CL <br /> eves -tP.rr►rc � nafi r olrt � � , vtcu� i �t � (Ar> C, — 1v� . �+ 1 ( �OCZsse <br /> p 5 <br /> e VLv l � � � �-� ( o C 'IZ5v1 b� u l� S-2X1Sb ►(3 t <br /> w {-rt � ss� d FYI M p � pivt -�' 9 �if� � ss �csfi�i� . �� joass� d, q I <br /> R4 ..pa4Ys tAjQ re, rn on ql� 1pio iYlSld c, the <br /> eJ79 a i 7 std <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD Inspecto Receiv Title : h fl r, (A <br /> EHD 23-04 Rev, Co :7� <br /> UST SERVICE REQUEST INSPECTION REPORT <br />