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oP��tN•.c SAN JOAQUIN COUNTY <br /> �Fl ENVIRONMENTAL HEALTH DEPARTMENT <br /> c• 'a <br /> yi 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> ' • P 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 Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> `I ! _ r-1Jca_— '!3�!,00 16142 <br /> Onsite Service T ch 'Clan's Name: ICC Service TeChnicianMStalier Exp.Date: Manufacturer Training: <br /> �kr i c <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El1-1mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: <br /> ❑ line test programmed 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 /> �-_' 1 ­II2 sensor <br /> lapositivL shutdown Model: yQ Z,4 El <br /> piping testing at: <br /> El psi <br /> -P fail safe Serial #: <br /> El NA minutes <br /> sensor ____// Secondary containment testing for: <br /> 0 positi a shutdown Model: VYt- Z''Tj UDC(s) Piping <br /> 1;2 fall safe Serial #:1;L, _-Lrja , 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 /> ElNA 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 /> 5� ,�74 <br /> 1 'zO-6 5A) <br /> �� ►' zA 5 N _ , G <br /> C2 -74 <br /> S�-�• s �sv� �% i.•t�4 Stens='r-f <br /> THIS FACILITY IS SUBJECT TO REINSPECTION NY_ IM"T EHD'S CURRENT HOURLY RATE. <br /> EHD Ins p r: Received y: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />