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Op4Ur~' C <br /> ?''�t'•O� NW, SAN JOAQUIN COUNTY <br /> Q: <br /> —�� ENVIRONMENTAL HEALTH DEPARTMENT <br /> I 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �. Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> ,CiF04/ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Faclility Name: Inspection Date: <br /> M(Iscli, <br /> acility Address: Service Request A: <br /> LQ M cc c CA q 5ac5S <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> 10 q-12- 3 0 2 -3- L <br /> SERVICE SERVICE <br /> Leak detector c.,+u h tt-le t n minimum .9 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hol T' <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Cad <br /> Leak detector lion <br /> El El mechanical Model: El El 1 ho <br /> Elelectronic Serial #: El Calc <br /> 71 line test programmed :: IC11 I <br /> Sensor fill, ril If I -:Ia IV r,l r,F:'f1 <br /> Xpositive shutdown Model: Primar r1 r: <br /> ❑fail safe Serial#: ❑ <br /> ❑ NA <br /> sensor Secon, <br /> ❑ ❑ positive shutdown Model: Piping <br /> ❑ fail safe Serial #: UST(s) <br /> ❑ NA <br /> sensor ❑ Testin, t due by: <br /> El ❑ positive shutdown Model: rt ;I_If IF <br /> ❑ fail safe Serial#: <br /> NotePie, L+1: 4'EIl: Ck k ri r! otestae upon <br /> 11 NA : „,. pa. .. <br /> installatior <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold a <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑) Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> pit This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> ( ` 5' 5h w <br /> Srl L& e V, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION Aj ANY TIME jIlIT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received 8y' _ Title: <br /> EHD 23-04 UST SERVICE REOUE INSPECTION REPORT <br /> Rev 4/30/12 <br />