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o.P4`'''tN•.c <br /> SAN JOAQUIN COUNTY <br /> a '2 \/tNVIRONMENTAL HEALTH DEPARTMEN%0- <br /> 0 <br /> w i <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sioov.org/ehd <br /> �IFOR <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> d M Lo A•n FSI <br /> Facility Name: Inspection Dale: <br /> (z Ot+-ZS-20 43 <br /> Facility Address: Service Request#: _ <br /> c/Z53 � Lew, &0(0S <br /> Onsite Service Technicia ' ame: ICC Service Technicianlinstaller Exp.Date: Manu c urer Tr fining: <br /> Amu 16umj�= <br /> i « / �n�3 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed El Caldwell System ❑ Other <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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fall safe Serial#: minutes <br /> ❑ 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 /> El ❑ positive shutdown Model: <br /> ❑fall safe Serial#: Note: Please ba aware that r containment components are required to be tested upon <br /> ❑ NA installation,6 months after,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 /> bn'lgl <br /> ❑ This UST facility is APPROVED to operate This UST fasililyy is NOT APPROVED to operate <br /> 144-s * \ <br /> r & .� •or � brtLel <br /> r A 140 L14OWD1211 <br /> r - (¢ <br /> L G <br /> V?- <br /> THIS FACILITY It SUBJECT TOR INSPECTION A ANY WME AT EHD'S CURRENT HOURLY RATE. <br /> EH s ctor: Received By: Title: <br /> r <br /> r <br /> EHO 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />