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�., SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> 71elephone:(209)468-3420 Fax:(209)468-3433 web:www.sioov.ornj/ehd <br /> a• <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION EPORT <br /> Pacillty Name: ' Inspecdon Date: <br /> Faelli y Addreso: - Service Request a1~ <br /> r 1 <br /> I r _ AI, �' Yj ICIL� I Ui't I L'i LM1 ey, .K lJ �1 <br /> onah�8o Ice Techniclan'a Nama: IC agrvlca TechnlCiennn Ilan Exp.Date: Ma u;.icturer Training: <br /> �y,i• i r ✓� 1 <br /> Cyst i � L :eZ. L�W2`e Y <br /> SERVICE SERVICE <br /> Leak detector &l, 'S 1 1 Spll`rt0cket jM minimum 5 gal on <br /> ❑ O mechanical Model: &] .&1 hour hydrostatic 173 Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector _Spill bucket 0 minimum 5 gal on <br /> ❑ ❑ mechanical Model: E] ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial M. ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> 9,17 Ft I I sensor Primary piping testing at <br /> ® ❑ positive shutdown Model: r-143 W-Lq— ❑ _psi <br /> ❑ fail safe Serial#: r"t gai! tiZ_ minutes <br /> ❑ NA <br /> 5� P It sensor Secondary containment testing for: <br /> ❑ positive shutdown Model: 2ijel UDC(s) F iping <br /> ❑fail safe Serial#: e 44,- S 7, ' —SumFI(s) T, LY• it l�, ST(s) <br /> ❑ NA f' 1.1 1 144 rr ON k <br /> sensor Testing for the above Components are next due by. <br /> ❑ positive shutdown Model 341) 701 <br /> ❑ failsafe Serial#: Q_r04)_ZI1, Note: P""to twroomm.m mco va,w mreour.dto t.rra.wt, <br /> ❑ NA q I .m.mmr,6momh.w..t4. 3enwm.r"iter. <br /> r tube ith mgehanieal gv ill at 95% ❑ Cold start of monitoring panel <br /> ❑ _Drop tube with mechanical overfill at 95% O Corrosion protection <br /> ❑ Overfill prevention (see LO letter 150-1) 1 ❑ Other: see below <br /> This UST facility Is APPROVED to operate 0 This UST facility Is NOT APPROVED to c perate <br /> 4Y r Bc PI I1 �Wj 6it414,1c, I' 1 F <br /> Bali p_ /� N11 . '�rivioJ- r,r.r ft r \ ,l <br /> r n r i r` ,l,'_ . [1 -1 ' �i �� 4� , <br /> j t <br /> ('(r L, � vivi te l' - 1��� e1 1 f� tt '1 ! � � G "+. 1. f Air <br /> '1l� ;i F : ' ,c r",�v7r., /" IA`^r) .1 - � I .I ti- � �i n - r.4F' ± ftuis i• s f, .�. <br /> j <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RAt. <br /> END IrteOeCton Ra Ived Ery:,. ; Title: <br /> / <br /> EHD 23-04I (_ V$T S12 `10E REOVEST IN ECTION REPORT <br /> Rev1We&1e <br /> £T/2T'd 6T8£LL6998T:o1 L0ES2£8602T dols Nonal A3Ual:W0ad TS:bT £T02-9T-dUW <br />