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°P4utN 'O SAN JOAQUIN COUNTY <br /> '-q-'ENVIRONMENTAL HEALTH DEPARTMENtf <br /> N: < <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> Ci'rG%FORa`4 <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fa ; Inspection Date: <br /> 'li� % <br /> - 13 - I <br /> Facility Address: Service Request : <br /> t G . I w Lr GA SRIYS_ <br /> Onsite Service t�ech``nician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> �S4Ac, /t�de✓&� o f X112 9-711-N, VtAl <br /> SERVICE SERVICE <br /> Leak detector — Spill bucket 11 minimum 5 gallon <br /> mechanical Model:T �✓ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: 11 Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> EJ electronic Serial#: El 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 /> El ❑ positive shutdown Model: UDC(s) Piping <br /> ❑ fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fad safe Serial#: Note. Please be aware that 20 containment wrn onents 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%q ❑ Corrosion protection <br /> Overfill prevention (see LG letter 150-1)", yw ���,,,qqq Other: see below <br /> El This UST facility is APPROVED to operate �r This USTfacilityis NOT APPROVED to operate <br /> 010, 'Ulkc <br /> dlNnl t�u� - <br /> 0 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION ATA Y TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe R ceived By: Ti �/ <br /> Q(y�i/t:L' iA <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />