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�quly <br /> z•�.r•.oG SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> y' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> P. Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s'goy.org/ehd <br /> �<rFpYR~ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: t Inspection Date: <br /> -maCC i eVCOn C) - II - 1 `1 <br /> Facility Address: I Service Request#: <br /> /y c�h l^ S 00 -20 4 ti a <br /> Onsite Service Technician's Name: ICC Service TechnicianAnstaller Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Laak Horn-*— <br /> ❑ mechl Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electrc El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ lin( ❑ Caldwell System ❑ Other <br /> LE <br /> Spill bucket El minimum 5 gallon <br /> El ❑ mecha <br /> ❑ electro PRESSURE LINE LEAK ALHR ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line u 1 :REGULAR ❑ Caldwell System ❑ Other <br /> PLLD SHUTDOWN ALARM <br /> fiEp 11 , '=014 9:05 AM❑ positivf Primary piping testing at: <br /> El El fail safE Elpsi <br /> ❑ NA minutes <br /> Secondary containment testing for: <br /> El ❑ positive UDC(s) Piping <br /> ❑ NA <br /> ❑fail safe Sump(s) UST(s) <br /> ❑ <br /> -- SEt83OR ALARM -- Testing for the above components are next due by: <br /> El ❑ positive L15:U7 STS' 2ul"IF' <br /> STP SUMP <br /> Elfail safe FUEL HLE+RM Note: Please be aware that Y mntainment components are required to be tested upon <br /> ElNA EF' 1 1 2014 05 AM installation,6 months atter,and every 36 months thereafter. <br /> ❑ Drof b ❑ Cold start of monitoring panel <br /> ❑ Drop ❑ Corrosion protection <br /> ❑ Overfill pre% .. .1 tsee LG letter 150-1) Other: see below -7 <br /> [ 7 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Q t \G h4 12,-7 l Yji n� Sal 0 w n <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received Title: <br /> F A/ I -y"' ' <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />