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SAN JOAQUIN COUNTY <br /> —c Z' ENVIRONMENTAL HEALTH DEPARTMENT <br /> �. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPCRT <br /> Facility Name: Inspection Date: <br /> ct r-- Gt- d-5-.201 <br /> Facility dress: Service Request#: <br /> Ib�I r►Cke- a S-9,C)0-4 64$3 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date. Manufacturer Training:C-5 <br /> .rte <br /> rle.Q, -3— <v-a-1 --kci mov, 14-1 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: El <br /> bucket ❑ minimum 5 gallon <br /> 771 El El❑ electronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> El 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 <br /> ❑ ❑ positive shutdown Model: Nraps iping testing at: <br /> ❑fail safe Serial #: <br /> El NA minutes , <br /> sensor Secondary containment testing for:61 <br /> ❑ ❑ positive shutdown Model: _ (XI 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: 1✓/)lr- <br /> ❑fail safe Serial #: Note: Please be aware that 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% ❑ 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 /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> A 'T � -; on (- O�� <br /> 310 v,5u c L- '; • e 3A <br /> 2 <br /> CDC ` Z — 6le sti <br /> lost UDC- 514 — q bt;� • 111A UtA QIDC-314 <br /> ODC -- 5� ODIC, - � <br /> THIS FACILIT IS SUBJE TO REINSPgCIjQ.N ATA TIME AT EHD'S CUR ENT HOURLY R TE. <br /> EHD Inspect Received By Tit I q� <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />