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SAN JOAQUIN COUNTY <br /> 2: <br /> .T •.2 <br /> -� ENVIRONMENTAL HEALTH DEPARTMENT <br /> y > 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> koa��P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> x-101 <br /> Facility Addre s: 0 P Service Wequest#: <br /> GrH �P3- V. 5-Pcot-cf0l <br /> On ite Service Technician's Name: ICC gervice Technician/Installer p.Date: Manufacturer Training: <br /> C) oll C)-o NJ co <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ElEl❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> 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: ❑ Primary piping testing at: <br /> El El <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment testing f r: <br /> El Elpositive shutdown Model: UDC(s) Piping <br /> ❑ fail safe Serial #: Sumps) UST(s) <br /> ❑ NA <br /> sensorX Testing for the above co ponents are next''due by: <br /> El positive shutdown Model: y�g�n�'(.� l V1StvLa <br /> ❑ fail safe Serial #: Note: Please be aware that 2°containment components are required to be tested upon <br /> ❑ NA Iinstallation,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 /> An <br /> oO:L <br /> e a. Vj j <br /> QxkauaAW� data I <br /> THIS FACILITY IS SUBJECt TO 9EINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receive ,By,: Title: <br /> OL <br /> r <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />