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o.P4ulk c <br /> r SAN JOAQUIN COUNTY <br /> X +'ENVIRONMENTAL HEALTH DEPARTMEN18i <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> . .._..P Telephone: (209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> ORN\ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: - Inspection D te: <br /> 4 4W-2,-3/13 <br /> Facility Address:: I G', 1 service quest#: II_- 1 <br /> Onsite Service Technician's Name: Ice service TechniciaInstaller p.Date: Manufacturer Training: <br /> rL2 ILA <br /> /3 s <br /> SERVICE SERVIC <br /> Leak detector <br /> ❑ mechanical Model: _Spill bucket Ll minimum 5 gallon <br /> ❑ El❑ electronic Serial#: ❑ 1 hour hydrostatic ElIncon TS-STS <br /> L1 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 PfDing testing at, <br /> El ❑ positive shutdown Model: 15Z _psi "� t�t�-+") <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 /> ❑ fad safe Serial#: Note: Please Ee aware that 2°containment components are required to tre 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 /> V[:Ov:e:r:fi:ll <br /> Drop tube with mechanical overfill at 95% ElCorrosion protection <br /> 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 /> CIV C" o� 4I <br /> TH S SUBJECT TO REINSPECTION AT ANY TIME AT EH S tURRENT HOURLY RATE. <br /> EHD Ins dor: Received By: Title.. <br /> 5 <br /> EHD 23_0j UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/ <br />