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op4u/y.. SAN JOAQUIN COUNTY <br /> 2' l_ <br /> ENVIRONMENTAL HEALTH DEPARTMENT-1, <br /> H •< 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> _ P Telephone:(209)468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> 44iFORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> YPILCA -Yf� �C. 01 - is -2ve, <br /> Faci ty Ad ress: Service Request#: <br /> l5 3 5 aw- P`o- Cace,(V Avc, T 00LA <br /> Onsite Service Technician's Name: ICC Service Technicianllnstaller Exp Date: Manufacturer Training: <br /> 2(f'(•t�U Lev- o 14 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> t4jAjensor c[hK � Primary piping testing at: <br /> ❑ positive shutdown Model: Q 0� ❑ psi <br /> ❑ fail safe Serial #:- Q::l minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> El El <br /> positive shutdown Model: <br /> ❑ fail safe Serial#: Note. Please he aware that T containment components are required to tte 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 /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> This UST facility is APPROVED to operate ❑ This UST facility is <br /> is NOT APPROVED to operate <br /> 1 <br /> ff <br /> S . - , <br /> THIS FACILITY IS SUBJECT TO REINSPECTIO T ANY TflqE AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: cei e Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />