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�••--._�'•P SAN JOAOUIN COUNTY <br /> ¢• �w- � ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazeiten Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility me: Inspection Date: <br /> _q ' 1 S <br /> Facility d ess: Service Request�: <br /> v-4$ W <br /> Onsite Service Technician's Name: erv' nlln taller Exp. Date: Manufacturer Training: <br /> V;c r -- <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 11 line test ro rammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ElEJ❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor <br /> E] El shutdown Model: ❑ Primary piping testing at: <br /> si <br /> F-1failsafe Serial #: p <br /> 7-1 NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA1.11 <br /> sensor Testing for the above components are next due by: <br /> F_ <br /> , ❑ positive shutdown Model: VVI�tVI: g5y� L1g640XX, <br /> ❑ fail safe Serial #: Note: Please be aware that 2'containment components are required to be tested upon <br /> ❑ NA installation,6 mcnihs after,and every 36 months thereafter <br /> ❑ I Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring pane! <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 /> -�o 69 wz ve.. �— - tea- LA <br /> 5 a Vjf�Uar f <br /> l2 � v <br /> v\ nrl u, <br /> V U �n -+n�� off <br /> THIS FACILITY IS SUBJECT TO REINSPECTION kT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect Receive E�y Title: <br /> EHD 23-04 UST SERV EQUEST INSPECTION REPORT <br /> Rev 4/30172 <br />