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OPgUIN C <br /> SAN JOAOUIN COUNTY <br /> TY ENVIRONMENTAL HEALTH DEPARTMENT <br /> cn.ICA x <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 REPORT <br /> Facility W e: Inspection Date: <br /> -1��15 <br /> Facilit ddress: Service Request#: <br /> ( ~I� , D-i5b <br /> Onsite Service Technician's arse: ICC Service Technicia A4sta xp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket 1:1 minimum 5 gallon <br /> F-1 ❑ electronic Serial:: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> ❑ <br /> El fail safe Serial #: ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment testng f <br /> ❑ ❑ positive shutdown Model: 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: Jo0t-, ,t <br /> El 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 4K This UST facility is NOT APPROVED to operate <br /> I <br /> Ngm :e'a IOWA <br /> r ! O e 1 — W u, <br /> C-III - 0'-"ar icekcw U 52r - r <br /> • <br /> t;40— IL� 0.h/ p <br /> THIS FACILITY IS SUBJECf4O REINSPECTION XT ANY TIME AT EHD'S CU RE T HOURLY RATE. <br /> EHD Ins too�jrr:���� Receive Title: <br /> EHD 23-04ee p ( r UST SERVICEIREQUEST INSPECTION REPORT <br /> Rev 4/30/12 NO b�o��`�C f� 0. "1 "" `�C,Q VIe 0'� l 1 1 sQ-'-- ���i — <br />