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QytR� SAN JOAQUIN COUNTY <br /> ��i-- ..� .r.,cNVIRONMENTAIHEAITHDEPARTMENT <br /> S 1868 East Hazelton Avenue, Stockton, CA 95205�3aoy.Oralehd <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web: _ — <br /> (i F Dtll�\ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Inspection Date: <br /> Facility Name: i 13 3 / ! t o /Z O l t 1� Z;20_I I <br /> OS-t c o b ! <br /> Facility Address: Service Request#: <br /> I616 E . HotRlfkIr LopQ , sfakfar - (R00 �6Iy <br /> Onsite mice Techniyian'y Name: ICC Service Technician/Installer Exp.Date: Manufactur r yring: S�`f vn Zll <br /> r: <br /> Alli-MCS( saM 'N SI`y-6cfR LVT� f/Z2/zol�} Jcedr.rese� b� 8•-78 3/t9/�5 <br /> Ig ar� 4J tr : .gosh I ii- r BO (,0�It c�-rl -f' " v <br /> SERVICE SERVICE <br /> g '11 detectors y 5 J p c Spill bucket minimum 5 gallon <br /> ❑ mechanical Model: <br /> electronic Serial#: IA 1 hour hydrostatic El Incon TS-STS <br /> El test ro rammed ElCa dwell System ❑ Other <br /> Leak detector 41114 114 <br /> Spill bucket ❑ minimum 5 gallon <br /> ❑ El mechanical Model: El IJ1 hour hydrostatic ❑ Incon TS-STS <br /> L1 electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System LlOther <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: El _psi <br /> ❑fail safe Serial#: <br /> ❑ NA minutes <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 E Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fad 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 /> ❑ Drop tube with mechanical overfill at 95% 1� Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> Overfill prevention (see LG letter 150-1) ❑ Other: /i see/below <br /> 6 iS a: rl pno kf-T it T'.rse `fz, i k hi ZD qM <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> rp45 �bS[ry Uer; lCa4ior P � al� Sehsor Ivtnc �/crvtaQ, a� e1M AILD �� GAe3RxisFi cis <br /> t VST "w sttt anf�l0.r Seytsars Cf'j�til fo "Ja '13 ji, 2fo I senor modH�� �tbe eR <br /> S i `l h roll dis(in isl Bbl rhv, ltrfksarSOYs 5 tI ot✓14 r.ts ;?Iacmt ►t'W vetA ' Lox-%hSaK <br /> '' <br /> no'kA *Vii S n So 1/ P + V �" rMs uli <br /> twk --Rit P VST tm. C� i oll oue' �5 a cL <br /> re r if ArW Vf i 'tC H'cic,>1 I So b ✓ eU it2 k& 4 r. 6s lc -k4 <br /> and S 4�bn C tc' <br /> sa (/,moble ✓PIrF 4lra✓N t/ti 1Vfovt-� S f draw' Wwtu <br /> T IS FACILITY IS MUBJECT TO RFINS P TION AT ANY TIME AT FH D'S CURREN HOURLY RATE. <br /> EHD Inspector: Q��3 3 Received By: Title: <br /> f myEHD 23-04 ( YH'�tRb V'eY^ Y-2 /� ,f1 1I I 44T SERVICE REQUEST INSPEc,TION REPORT <br /> Rev 4/30112 B /J c�0 M� �•2 j150r �l� ✓k vJe✓�c� b�wq� s r2Dl Ua.L P.Ot Wrr� Ire B1d t"laJc SPMsor ✓ moyfd <br /> Frotr qIO�i�rlllt sJ I Pr N waz tTFrslred cv�d 1 passed <br />