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�qulN c <br /> �°•�.�'••,o� SAN JOAQUIN COUNTY <br /> h y< ENVIRONMENTAL HEALTH DEPARTMEN <br /> 186 East Hazelton Avenue, Stockton, CA 95205-b 32 <br /> .. :P Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.siciov.org/ehd <br /> '9ClFOR� <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> J/-71 11 Oil 69, 12111 11z <br /> Facility Address: Service Request#: <br /> 35/5 NkrMDr s'tOG�to Spoota56]g4 <br /> Onsite Service Technician' me: ICC Service T�echnicianlinstaller Exp.Date: Manufacturer Training: <br /> jh Oals o I <, q zgli3 -u?" 7 X, <br /> SERVICE SERVICE <br /> _Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> _Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ _psi <br /> ❑ fall safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) _Piping <br /> ❑ fall safe Serial#: �Sump(s) UST(s) <br /> EI NA <br /> sensor Testing fpr the above components are next due by: <br /> ❑ ❑ positive shutdown Model: W// 11,4 <br /> ❑ fail safe Serial#: Note: Please be aware that 2°containment components 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 ❑ This UST facility is NOT APPROVED to operate <br /> #oZ <br /> R s <br /> r <br /> e, r <br /> �fbdla <br /> T FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins or: Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30112 <br />