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�V!fy. <br /> 10�N]4!�1_y <br /> 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.or /ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> P� <br /> Facilitk Address: ServiceRequist 9: <br /> x <br /> Onsite Service Technician's Name: ICC Servicerrechniclanil Date: Manufacturer Training: <br /> r <br /> SERVICE SERVICE <br /> Leak detectorSpill bucket Ll minimum 5 gallon <br /> El 11 mechanical Model: d) A�i-1 hour hydrostatic 11 Incon TS-STS <br /> El electronic Serial: <br /> El Caldwell System D Other <br /> El line test programmed <br /> Leak detector Spill bucket [I minimum 5 gallon <br /> El 11 mechanical Mlodei: El El 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial El Caldwell System 0 Other <br /> Ll line test programmed <br /> sensor❑ Primary piping testing at: <br /> El positive shutdown Model: ❑ psi <br /> 11 fail safe Serial #: minutes <br /> El NA <br /> sensor Secondary containment testing for: <br /> 17 E positive shutdown Model: U DC(s) Piping <br /> Ll fail safe Serial Sump(s) c5e <br /> —t UST(s) <br /> El NA 142 j /-./, a, I k,, - <br /> da <br /> sensor Testing for the above components are next by: <br /> [_1 positive shutdown Model: k1A <br /> D fail safe Serial #: Note Please be aware that 2'containment components are required to be tested upon <br /> 0 NA installation,6 months after,and every 36 months thereafter, <br /> ❑ Drop tube with mechanical overfill at 95% L1 Cold start of monitoring panel <br /> El Drop tube with mechanical over-fill at 95% Ll Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) M Other: see below <br /> This LIST facility is APPROVED to operate El This UST facility is NOT APPROVED to operate <br /> JL4_AA� -&S �-- 06Nmej <br /> tv-�k_ <br /> r <br /> Or, Z- 14-12, ' <!�brry-w-L- 1 , <br /> -X4 <br /> All --h­3-15 rrf <br /> THIS FACILT t]YISSR,jFdTTC) RFINI;PECTIONATAWEH <br /> D'S D'S CURRENT HOURLY RATE. <br /> 12 � <br /> EHD Inspe6orIlec <br /> / Title:701 I <br /> EH I)2304 /- UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/0-6710/ <br />