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/? •••�� oo. SAN JOAQUIN COUNTY <br /> ly�..,��� F �: ENVIRONMENTAL HEALTH DEPARTMENT <br /> t i�llt3 1368 East Hazelton Avenue. Stockton. CA 95205-6232 <br /> ' Telephone: (209) 468-3420 Fax:(2C9) 468-3,133 Web:w',v'N.sirov.er,lehd <br /> �CikoRN. <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 0"deuce- 0ST -; 2.0 18 <br /> Facility Address: Service Request#: <br /> _ ";Pl 0012-q 123 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: Manufacturer Training: <br /> a�0., - �10 Kiw - Ack <br /> SERVICE SERVICE <br /> Leak detector <br /> 11 mechanical 1rlodel: Spill bucket ❑ minimum 5 gallen <br /> [IElElEl electronic Serial 1 hour hvdrostatic Incon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> El line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El electronic Serial #: ❑ El1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor I Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Sec ndary containment testing for: <br /> ❑ ❑ positive shutdown Model: AW UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor X Testing for the above components <br /> __X are <br /> � next due by: A <br /> E] El positive shutdown Model: �eAV 1 p N/PH ,IA.An �+"t CS14T_ <br /> El fail safe Serial #: Notes Please`aware that 2'containment components are required to be tested upor. <br /> ❑ NA installation,3 months after.and every 36 months thereafter. <br /> ❑ Drop tube with mechanical overfill at 95 ❑ Coid start of monitoring panel <br /> ❑ Drop tube with mechanical overfill a 9500 ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate This UST fac' ' y is NOT APPROVED to operate <br /> a6(- 5 C4 - <br /> l - a.� u <br /> f.. l ouj e,,r►ne- r <br /> L 0,Ad I,9 Vwc� — <0 y t- <br /> 0,4 W0,6 <br /> b 0-40 <br /> D p.viii/ Y.rx Vie ot ' on G u o©rnmPW <br /> THIS FACILITY IS SUBJECT TO REINSP CTIOAT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp or. Pj � � Title-� <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30;12 <br />