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ot+- 6.IN• <br />a•.t'' ,& • SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />W. <br />` 1868 East, Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax., (209) 468-3433 Web: www.sigov.orq/ehd <br />UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br />Facility Name: <br />1 <br />Inspection Date: <br />F7 <br />❑ electronic Serial #: <br />Facility Address: - <br />Service Request #: <br />Onsite Service Technician's Name: <br />ICC service Technicianlinstaller Exp. Date: <br />Manufacturer Training: <br />❑ mechanical Model: <br />It3 ,1.,, <br />❑ electronic Serial #: <br />SERVICE <br />ElElmechanical <br />Model: <br />� <br />❑ electronic Serial #: <br />❑ line test programmed <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Leak detector <br />❑ <br />❑ mechanical Model: <br />0 <br />❑ electronic Serial #: <br />❑ line test programmed_ <br />sensor <br />JK •-d££SH�OCGH <br />mDDmoDro <br />1K 3HH—\rrW <br />rommcjc Dc•• <br />>Ic ."tli720CL]3t7 <br />arrtnm - <br />* O 3 D U <br />x r m m hi <br />m <br />O m <br />00 N m W F m <br />M_ co - • WU1O\W <br />D II+MWWM <br />W U100WW❑m0 <br />W r7 c� c c� c <br />W oororrrr <br />=MMIMMMM <br />'n m m <br />U) U1 <br />'-1�cr2 Hw CC•i <br />mDDmr0 <br />IV H m -;< X \ r r N <br />IV 1-11Z1ZHt0"tC-'m[i1C <br />o <br />r mm kD <br />11 II II. II II II It II <br />A- <br />U O 001 - <br />�0 • A O UI A <br />tO O <br />-.lO DMWMOW <br />t;I-;Q;•cz000 <br />M z D 3>3>3>D <br />c �rc�rrrr <br />•nmWmm nr to <br />M rn <br />vIUIJ LUUC Winn II IOU IGI IIVgI VVCI 1111 Hl OU70 <br />❑ Overfill prevention (see LG letter 150-1) <br />This UST facility is APPROVED to operate <br />SERVICE <br />�Ne,%;L4 Spill bucket <br />4&1 hour hydrostatic <br />❑ Caldwell System <br />Spill bucket <br />❑ ❑ 1 hour hydrostatic <br />❑ Caldwell System <br />H££= H m C C H <br />mDDmc�ora <br />ro171ri-• err <br />mmc�C Da•• <br />zx1 HmCf"m3m <br />C =171 r <br />r m� m <br />n II n 11 11 it 11 11 <br />M <br />00 UImmmm <br />. O 001M+ W <br />moowW -'NN <br />M <br />m z Do D D D <br />c D <br />MMMMrrr <br />"1 u]mUJ iA tO <br />rn M <br />I <br />z <br />tC*1 r I K <br />C) r H <br />O `n Im <br />3 <br />,LI <br />O z I C <br />z to rn <br />i z <br />X10 <br />rl� <br />i <br />u Lorroslon protection <br />❑ Other: see below <br />❑ minimum 5 gallon <br />❑ Incon TS -STS <br />❑ Other <br />❑ minimum 5 gallon <br />❑ Incon TS -STS <br />❑ Other <br />4 W W p m <br />z DOD z <br />UI 0 � <br />❑ This UST facility is NOT APPROVED to operate <br />� <br />pam <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />Nz3>M <br />Received By: <br />l� - .- � <br />Title: <br />-T1 �h <br />0 <br />0Diz <br />alum• <br />0❑Dr-� <br />000 <br />N <br />0 m <br />N <br />m <br />and <br />ro <br />3 <br />❑ This UST facility is NOT APPROVED to operate <br />EHD 23-04 v UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br />EHD Inspe <br />4�^ <br />Received By: <br />l� - .- � <br />Title: <br />-T1 �h <br />EHD 23-04 v UST SERVICE REQUEST INSPECTION REPORT <br />Rev 4/30/12 <br />