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SAN JOAQUIN COUNTY <br /> o yyy�== qqq" ENVIRONMENTAL HEALTH DEPARTMENT' <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: // Inspection Date: <br /> Facility Address: t Service Request : <br /> 7077 C t Yese,- ,,Aq Ave. 2 ll I" e4 5`K 0l ' <br /> Onsite Service Technician's Name: ICC Service Technicianllnstaller Exp. Date: Manufacturer Training; <br /> D0,11l M Kler VM1 11 /12 //7 <br /> SERVICE SERVICE <br /> Leak detector ] <br /> 9 mechanical lvlodel L 9q 1)'2063 —Spill bucket ❑ minimum 5 gallon <br /> Ix ❑ electronic Serial #: /S / /3 ❑ ❑ 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 /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: Primary piping testing at: <br /> F1 fail safe Serial #: El Primary <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial #: <br /> El NA Sump(s) UST(s) <br /> sensor El Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: <br /> ❑ NA Note: Please be aware that 2°containment components are required to be tested upon <br /> installation,6 months akar,and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> E] 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 NOT APPROVED to operate <br /> QnW shlesss -rn —r/Ze rlioa 11A 1 <br /> 877- o e LD -2060 hil I 'i Je&iA=. he V <br /> 0d&nza a" <br /> THIS FACILITY IS SUBJECT TO REINSPqrTION A ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: L�le�//7 Re t By. Titley <br /> EHD 23-04 ��! UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />