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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> P Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> S SI <br /> Facility Name: Inspection Date: <br /> " X119Z& Df'- 0q - 24LZ <br /> Facility Address: service Request#: <br /> : -n s P Twq 51 v, Trno <br /> gnslt Se tce Technician's Name: ICC.Servic T�,ech icianllns Iter Exp.Date: c w���r T.Taining: <br /> N HOl► V t) I Z£5r. f( 7mI� / 7lFnk N s+�neMr1244 2 <br /> SERVICE SERVICE <br /> _Leak detector uc/fS �k <br /> et <br /> F1 11 <br /> ❑ mechanical Model: r Spl j minimum 5 gallon <br /> 91 hour hydrostatic ❑ Incon TS-STS <br /> El ❑ electronic Serial: <br /> ❑ line test programmed <br /> El Caldwell System EI Other <br /> _Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> El El electronic Serial #: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> 1-1 Caldwell System El Other <br /> l R I I sensorI/ � _�� Primary piping testing at: <br /> ❑ positive shutdown MOd ❑ psi <br /> ❑ fail safe Serial#: Q Cal 2_ minutes <br /> ❑ NA <br /> 94 Fj IL—sensor11 � Secondary containment testing for: <br /> ❑ positive shutdown Modb1Y_3`443k- mZ UDC(s) Piping <br /> ❑ fail safe Serial#: G hn�� JASumps) �Z� s�UST(s) <br /> El NA sensor / Testing or he ab e(components arenext due by: <br /> �( ❑ positive shutdown ModV---2114-3 <br /> �j ❑ fail safe Serial#: O'n I Note Please be aware that 2°containment components are required to be tested upon <br /> ❑VA installation,6 months after,and every 36 months thereafter, <br /> r tube V mechanical 3=ill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ I 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 /> 0 <br /> S <br /> 1 f77JAilool In 611 sttihV5 — pq S <br /> & S `GT <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD 1 or. R:7iv d Bey: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />