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Aqu1N <br /> QUIN <br /> a y SAN OLNVIRON ENTAHEALTHODEPARTMENT'*3 <br /> .- <br /> 1868 st Hazelton Avenue, Stockton, CA 95205 6232 <br /> Telephone: (209)468-3420 Fax. (209)468-3433 Web:www.sigov.org/ehd <br /> �%PORN <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: D/ <br /> FrY.� /� Inspection Date: <br /> I Lt Lts Z0 <br /> Fa ility Address: -n Service R est#: <br /> Uo <br /> Onsite Service Technician's Name: ICC Service Technicianllns[aller Exp.Date: anufacturer Training: <br /> m F <br /> -54141a <br /> 1"y I <br /> SERVICE SERVICE <br /> _Leak detector Spill bucket El minimum 5 gallon <br /> Fl El mechanical Model: El 1 hour hydrostatic ID Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System El Other <br /> ❑ line test programmed y <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial#: <br /> El ❑ mechanical Model: El Ely <br /> 1 hour hydrostatic ❑ Incon TS-SS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ NA <br /> El fail safe Serial#: Sump(s) UST(s) <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ •❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Note: Please be aware that p containment comPonenls are required to be tested upon <br /> ❑ NA installation,6 months after,and 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 /> This UST facility is APPROVED to operate t�11 ❑ This UST facility is NOT APPROVED to operate <br /> c. Q& <br /> THIS FACT ITY IS SUBJECT TO REINSPEC N TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe Re ved B : Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/'12 <br /> r <br />