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:E' •, SAN JOAQUIN COUNTY <br />c ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />' Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siaov.orglehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />Inspection Date: <br />F-ni'e 5 <br />1-2,-7-1-7 <br />Facility Address: 1 <br />Service Request #: <br />Onsite Service Technician's Name: <br />ICC Service Technician/Installer Exp. Date: <br />Manufacturer Training: <br />Other: see below <br />_IX <br />SERVICE <br />Leak detector <br />❑ ❑ mechanical <br />❑ electronic <br />❑ ❑ mechanical <br />❑ electronic <br />❑ line test Droare <br />sensor <br />Model: _ <br />Serial #: <br />Model: <br />Serial #: <br />N( -iE �=HIGCCH <br />mDDmC'iOrG <br />rommcJc rc•• <br />JK .Ufi=GCG)30 <br />�rrmm <br />e 3� m <br />m n n n u e n u n <br />nr* <br />LA " <br />J, S�0�0 <br />�. c--0 c:cc� <br />x cmz17,r- <br />-7TF- <br />=t=-l!=i- <br />[Ij U• <br />M nm m <br />co rr, <br />romm= c DC•• <br />r - <br />C, = Tx ro <br />G <br />r m <br />m <br />n n u n n n u n <br />P <br />00 rzw�— <br />�• wtomT <br />dOocnI MokD <br />mzDzDDSD <br />Q0t- rrrrr <br />mt=*lu:t=MMMM <br />U) co <br />SERVICE <br />)iey4 Spill bucket <br />lc�,1 hour hydrostatic <br />❑ Caldwell System <br />❑ minimum 5 gallon <br />❑ Incon TS -STS <br />❑ Other <br />Spill bucket ❑ minimum 5 gallon <br />❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS <br />❑ Caldwell System ❑ Other <br />m�xt=*rcyioro <br />rommc:c -•• <br />��HtG"C �1MZ <br />c c r <br />z - <br />tG 7`10 m <br />m <br />If It n n n n n n <br />P <br />M0M. . 000m <br />. • • r - <br />o m U mo w <br />— " W <br />rn--c:—c 000 <br />M D Z D D D D <br />"rl 17171 Wanti <br />C D I IT <br />On r J <br />G In I m <br />fi tz _ <br />z I <br />fi y <br />m _ <br />ro G <br />O z c <br />fi m _r <br />G 1 m <br />fi ro <br />n <br />r <br />,M, This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br />v.vV w.6 will II IIIA 101 IMdl UVCITIn dl V0%0 <br />u <br />corrosion protection <br />❑ <br />I Overfill prevention (see LG letter 150-1) <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />❑ <br />Other: see below <br />,M, This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 v� / UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />SII l v� I•+ <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Ins pec <br />Received By: <br />Title: <br />EHD 23-04 v� / UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />