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SAN JOAQUIN COUNTY <br /> e' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> p.. <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> �/POEN; <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facili Name: Q S (D.r" <br /> [inspectio_n Date: �j� <br /> Facility Address: ` p IZ <br /> 3 _ e ry equest#: <br /> Onite Service Technician's Name: ICC Service Technician/Installer Exp. Date: nufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector ill bucket minimum 5 <br /> ❑ L1 mechanical Model: P � gallon <br /> ❑ electronic Serial#: �1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System Omltherd <br /> _Leak detector Spill bucket imum 5 <br /> El ❑ mechanical Model: 1 houghydrostatic ❑ Incon TS-STS❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El ❑ positive shutdown Model: ❑ —psi <br /> ❑fall safe Serial#: <br /> ❑ NA minutes <br /> — <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 Nat 2'containment components are required to be tested upon <br /> NA installation,6 months after,and every 36 months thereafter. <br /> be with mechanical overfill at ❑ 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 /> n u <br /> ❑ This UST facility is APPROVED to operate is NOT APPROVED to operate <br /> i <br /> 9< a <br /> �5 i d.rivi <br /> V-nIova Fti.e i <br /> S <br /> Z , <br /> & Vg <br /> THIS FACILI IS SUBJECT TO R INSPECTION AT ANY TIME AT EHD'S CURRENT HOURL RA E. <br /> EHD Inspect Received By: Title: <br /> s� t� <br /> EHD23-04 U UST SERVICE REQUEST INSPECTION REPORT <br /> \4/30/12 <br />