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,. W 0 0 RECEIVED <br /> q2� M <br /> �0 SAN JOAQUIN COUNTY <br /> �. ENVIRONMENTAL HEALTH DEPARTMENT OCT 30 2014 <br /> U& 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siqov.orq/eh ENVIRONMENTAL I HEALTH <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTIONIREP V <br /> Facility Name: Inspection Data: <br /> Service Request <br /> Facility Address: <br /> #: <br /> _ ; ?rtnn Vii . <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <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 /> 11 ❑ <br /> ❑ ❑mechanical Model: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: ❑Caldwell System ❑Other <br /> ❑ line test pr2grammed <br /> sensor Primary piping testing at: <br /> 0 ❑positive shutdown Model: ❑ _psi <br /> [I fail safe Serial#: _minutes <br /> ❑NA <br /> sensor Secondary containment testing for: <br /> El ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA sensor ❑ Testing for the above components are next due by: <br /> El ❑positive shutdown Model: <br /> ❑failsafe Serial#: uwr Pbeae oeasamurm anmam�nv«am=arereWireamea ma as upon <br /> ❑ NA n abban,emaMhe ePs,aM ewryae mo Ms memeae. <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ <br /> Overfill prevention(see LG letter 150-1) ❑ Other:see below <br /> x❑ This UST facility Is APPROVED to operate ❑ This UST facility Is NOT APPROVED to operate <br /> ,Ptrtessed functionality verification testing of the waste water tank overfill sensor. including sensor o 1, <br /> 10assed. <br /> The sensor has been set to alarm at 80% of the tank capacity_ The length of the card at this level is <br /> a6 inches <br /> THIS FACILITYA SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD I w: Received By: T <br /> EHD 23-04 R 0417 2 UST SERVICE REQUEST INSPECTION REPORT <br />