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:... _ 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.s'aov.oralehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> FacilityInspection Date: <br /> r4, Y �aciEi r �1 22-19i <br /> facility Address: Service Request#: <br /> 3 LtY N . �.� � M SR Oros S ga <br /> qnsitq Service Technician's Name: ICC Service Technics !taller p.Date: Manufacturer Training: <br /> k6, 6r � Ja 5 2, - 4'fi3" <br /> jr <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑mechanical Model: Spilt 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 /> 13El❑electronic Serial#: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test r rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> Spill bucket ❑ minimum 5 gallon <br /> ❑mechanical Model: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ !noon TS-STS <br /> ❑electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> ❑positive shutdown Model: Primary piping testing at: <br /> El �•� . <br /> i q ISS <br /> 0 W 4L psi SAY fail safe Serial#: <br /> ❑NA minutes �N 102 (9 <br /> sensor Secondary containment testing for: <br /> ❑ ❑positive shutdown Model: UDC(!) Piping <br /> ❑fall safe Serial#: Sump(s) UST(s) <br /> ❑NA <br /> sensor Testing for the above mponents are next due by.- <br /> 0 <br /> y:❑positive shutdown Model: Cia 2 C I <br /> ❑fail safe Serial#: <br /> Note: Please be avarA that 2°containment components are requiretl to be tested upon <br /> ❑ NA installs' months after, nd 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 /> -!•resOr mkxcq ,� A" <br /> -�' <br /> d 4 r CC' t t " - ' <br /> -as <br /> ig <br /> l c a f;LA <br /> THIb FACILfff IS SUBJECT TO REINSPqCTION AT ANY TIME AT ADIS CURRENT HOURLY RATE. <br /> EHB Ins e i By: Witte: <br /> EHp 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 71!17!!08 <br />