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c. •!h. + • <br /> •'�`r''•. SAN JOAQUIN COUNTY <br /> a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> l g' Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> a� F0R+ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: t Inspection Date: <br /> S R H Fo od3 Gus 611§j- 17 <br /> Facility Address: Service Request#: <br /> 7y E. Dr. ✓✓1 iffy, Luther Kl)ij SR VVC) SR0077936 <br /> Onsite Service Technician's Name: ICC Service TechhtCiantinstaller Exp.Date: Manufacturer Training: <br /> Frecler/4k gc,5e. l 11 y <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> E-1 El mechanical Model:❑ electronic Serial El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El El mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> aNnv4r sensor <br /> Primary piping testing at: <br /> ❑ positive shutdown Model: ❑ —psi <br /> ❑ fail safe Serial#: <br /> ❑ NA minutes <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: Zf(t�`larl 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 /> ❑ fall 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 /> L)nsdfgtoIt unc ,onra�i p� f(n <br /> THIS FACILITY IS SUBJECT TO REINSP ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector:,s ✓ kv� R ived B : Title: <br /> EHD 23-04 _ UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />