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,q f� <br /> ?°'�t'•-P� SAN JOAOUIN COUNTY PP, U --'.—) 4 3 44 <br /> w ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> , p Telephone:(209)468-3420 Fax:(209) 468-3433 Web:www.sioov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> -4 - L--1e vQ-rl 3 -I - <br /> Facility Address: Service Request#: <br /> "Id, 1 2) eQ w QY DIY SSC DGS 00 <br /> Onsite Service Technician's Name: ICC Service Tec hniclan/installer Exp.Date: Manufacturer Training: <br /> O T�- -icc-- 0 f-1 - �1 - l Nov - 1 �- <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> E] ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: <br /> ❑ line test programmed ElCaldwell System ❑ Other <br /> sensor , ` Primary piping testing at: b 1q I clsV" <br /> E] ❑ positive shutdown Model: /At'S` 10-12 psi a-ud �/(Z OL (-LA-d C(I <br /> ❑fall safe Serial #: minutes o Acxd2 10 IP <br /> ❑ NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor ❑ Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> ❑ fall safe Serial#: Note: Please be aware mat 2°containment components aro requiretl to be tested upon <br /> ❑ NA Installation,s months atter,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 I This UST facility is NOT APPROVED to operate <br /> site —kite t <br /> ChA e 91 A-i"a C3 J Q.Ld cLAA& \/ o-r vip LDLoj24aA.Ld <br /> cleaL, - I . h ; -- <br /> 41 V - 10 .'A s i O, ` e <br /> �t 1 <br /> 6\m-e' - 10,1; <br /> THIS FACILITY IS SUBACT TO REINSPECTION AT ANY TIME AT EHD' CURB NT HOl-h'.V RAT . <br /> EHD Inspector: Received By,: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />