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o <br /> JOAQUIN <br /> UNTY <br /> 2' ENVIRO MA NTAALL HEALTHODEPARTMENTf <br /> a' a <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sioov.org/ehd <br /> �P <br /> 9<iFoaN` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: t Inspection Date: <br /> Facility Address: Service Request#: <br /> I I Lo E mrxc c <br /> Onsite Service Technician's Name: ICC Service Technician/Inst& er Exp.Date: Manufacturer Training: <br /> SERVICE <br /> Dose, Leak detector q <br /> �p ❑ mechanical Model: 0 1 El El hot Ion <br /> l i tkelectronic Serial #: -�(o rj8 1 0 ❑ Cald <br /> ❑ line test programmed <br /> Leak detector FRE.,SURE L I NE LEAK ALARM <br /> ❑ mechanical Model: _+ 3:1,IESEL Ion <br /> ❑ El 711 hot t3F.Ct:S LINE FAIL <br /> El electronic Serial #: El Cald Afa -• -'U t 5 9:21 AM <br /> ❑ line test programmed <br /> sensor <br /> ❑ positive shutdown Model: Primary <br /> ❑ ❑ fail safe Serial #: ❑ I <br /> ❑ NA I <br /> sensor Second <br /> ❑ ❑ positive shutdown Model: 'iping <br /> ❑ fall safe Serial #: PRESSURE LINE LEAP' ALARM IST(s) <br /> ❑ NA w 3:DIESEL <br /> ❑ F'LLD SHUTDOWN ALARM <br /> sensor Testing JAN 2. 2015 +:21 AM due by: <br /> El ❑ positive shutdown Madel: <br /> ❑fail safe Serial #: Note' <br /> ❑ NA installa,im,6 months after,and awry 36 months Hereafter <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 ❑ This UST facility is NOT APPROVED to operate <br /> h S b n ) <br /> d V: ' �(-Iuo064- IP^ <br /> THIS FACILITY IS SUBJECT TO REINSPEC ION AT ANY TIME AT EHO'S CURRENT HOURLY RATE. <br /> EHD Inspector: Race ted Title: <br /> j f Cr <br /> EHD 23-04 <br /> Rev 4/30/12 UST SERVICE REQUEST INSPECTION REPORT <br />