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>:• 61'•..0 <br /> c � SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMENiW <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �.• P Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sigoy.orq/ehd <br /> 4�tF ORS` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: ^ <br /> I FInspection Date: <br /> Facility Address: n Il equestS+0C.I c 5 260Onsite Service Technician's Name: ICC Service Te hnicianllnstalier Exp.Date: urer Training: <br /> 'Dart L. vcCTa'� 5?�Z ib� 91zq/l3 S�Cma "4^837 <br /> SERVICE SERVICE <br /> _Leak detector <br /> F-1 ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> _Leak detector _Spill bucket ❑ minimum 5 <br /> El ❑ mechanical Model: ❑ 1:11 hour hydrostatic ❑ Incon TS-STS <br /> llon <br /> ❑ electronic Serial#: y <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ fall safe Serial#: ❑ _psi <br /> ❑ NA minutes <br /> sensor Secondary containment tong <br /> L1 positive shutdown Model: UDC(s) � )fotr: Z Pipin I h <br /> ❑ fall safe Serial#: <br /> ❑ NA Sumps) UST(s) <br /> sensor Testing fort the above components are next due by: <br /> El ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: <br /> El NA Nate: Please aware that containment components are required to be tested upon <br /> installation,6 moo nths 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 ❑ This UST facility is NOT APPROVED to operate <br /> all Jk <br /> wk <br /> S <br /> I <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> E Inspe or: ✓ V -1,104,4r¢y Received y: Title: O <br /> �o f <br /> Rev R 23-0 UST SERVICE REQUEST INSPECTION REPORT <br /> Re4/30! 2 <br />