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SAN JOAQUIN COUNTY <br /> Q. +! ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> : <br /> �,�• Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility NInspection Date: <br /> a e: <br /> Facility Address: kiService Re Gest#: <br /> m9b •ro C b5&0-4-4 <br /> Onsite Service Technician's Name: 1 ice Technician/Installer Exp. D te: Manufacturer Training: <br /> 2iwa a-11 C)Puj q 17 <br /> i` - - 9 <br /> SERVICE SERVICE <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 /> Leak detector VL51 Spill bucket minimum 5 gallon <br /> El [Imechanical Model: )<1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed 7C <br /> sensor <br /> El El shutdown Model: ❑ Primary testing at: <br /> si <br /> ❑ fail safe Serial #: <br /> El 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 ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fail safe Serial #: Note: Please be aware that 2°containment components are required to be tested upon <br /> El NA installation.6 months after.and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95110 ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) IN Other: see below <br /> ❑ This UST facility is APPROVED to operate Thi UST facility is NOT APPROVED to operate <br /> �i V avi mw��, c <br /> 0 yk ik SWA'tA- ^k 0 —C4 U <br /> COUA-L-06 V1 x hili Lo <br /> UO t <br /> vl P� <br /> 51P <br /> AA <br /> THIS FACILITY IS SUBJECT TO 4EINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins�ecto Received Title: <br /> zzll <br /> EHD 23-04 l of -1 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />