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_'' —_- 'E 'Q� • SAN JOAQUIN COUNTY <br /> z y` ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton. CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> CA SU VY lei Ie low D cfi 23 t 2-0 1 T <br /> Facility Address: Service Request#: <br /> Hu -Fro Ck/ gjZooq_pL�q� <br /> ?a5o VV , JOr-qrm-Ine i <br /> Onsite Service Technician's Name: ICC Service Technicia nstaller xp.Date: Manufacturer Training: <br /> ��fiG G <br /> all( Za 9 <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 <br /> ❑ 11 positive shutdown Model: ❑ Primary psi <br /> piping testing at: <br /> ❑ fail safe Serial #: minutes <br /> El NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 21 containment componerts are required to be tested upon <br /> ❑ NA installation.6 months after,and every 36 months Ihereatter. <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 /> on we, it vjwfu coli u ndi c!l + mei UL-V_.g), jp <br /> V al ,VI n 'e. Gs <br /> Wo UCnvio_,RQon �. <br /> a S dot 1 ten a l <br /> �q o s ble e f n Din <br /> T v <br /> vvl &HID, <br /> THIS FACILITY IS SUBJECT TO REMPL-eYlOh A7 ANY TIME AT EHOS CURRENT HOURLY RATE. <br /> EHD Inspector: Flecei Sy' _ Title: <br /> JLU�C 04 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTIO REPORT <br /> Rev 4130/12 <br />