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P�tJfly , <br /> �o. �.cflG SAN .10AQUlN COUNTY <br /> ED <br /> is ENVIRONMENTAL HEALTH DEPARTMENT �O 2:; <br /> 1868 East Hazeitan Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (LIST) PROGRAP1 SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> al Mo 0CT- <br /> Facility Address: Service Request#: <br /> 37 \N �� +Ir]� lea DO �� S R <br /> Onsite Service Technician's Name: ICC Servi a Te hnicia nsta Exp. E)ate: Manufacturer Training: <br /> �� 2-0 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Madel ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> Ll mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial <br /> Ll line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: ElPrimaryppiping testing at: <br /> si <br /> ❑ fail safe Serial #: <br /> minutes <br /> Ll 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 /> 71 <br /> y:❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 2°cortainment components are required to be tested upon <br /> ❑ NA installation,6 months atter,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 /> �YT 10kJ20 1 - r-1 d)e <br /> gnSc,r- Con t,7i v m r 1 C <br /> - o -e w�I I V&I In In +z KGs <br /> NO & e <br /> lea � WI M n <br /> UCLONA C�VQM .ce j- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S dURRENT HOURLY RATE. <br /> EHD Inspector: Received T011(fj Title: <br /> A <br /> EHD 23-04 �� /! UST`SERVICE REQUEST INSPECTION REPORT <br /> Rev 4130112 <br />