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o.?Cku!N.•.c <br /> �. �� •o� SAN JOAQUIN COUNTY <br /> e: v .� -NVIRONMENTAL HEALTH DEPARTMEN <br /> `. 18bu cast Hazelton Avenue, Stockton, CA 95205 32 <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 Name: Inspection Date: <br /> q %ekA <br /> 'A oo! t ZQ r naw_-V <br /> Facility Address: Service Request#: <br /> lq�00 WabAtkire�� f4yau-pu r-e.A,`t <br /> Onsite Service Technician's Name: ICC Service Technician/I staller Exp. Date: Manufacturer Training: <br /> Gav►rP1 Vv lI iQ�S -�i- 201 v2 — 3-�-�4 ' �mT—;1 -is <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket 1:1 minimum 5 gallon <br /> F-1 ❑ electronic Serial:: El 1 hour hydrostatic ElIncon TS-STS <br /> L1 line test programmed ❑ Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> F1 electronic Serial: El El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed El Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Primary testing at: <br /> si <br /> ❑ fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor Secondary containment testing for: <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: <br /> ❑ ❑ fail safe Serial #: Note Please b aware that 21 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% X Cold start of monitoring panel Ll -Ll� <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 /> fUA s cad ate, L--2 <br /> r c A a-a I, glkd S 5e-a' SO-� <br /> -0*C( <br /> e- <br /> -C*a✓►e oe,,�and c e-,xEJL- Lvie Le" <br /> S Ve s\A_UjC &"Ov\ 50'r- V-1-t cuA4 o' S Q e , -vZ a� s of- <br /> i <br /> o 1A 01 C as L 24 t C h u hay_) ea►- --QtQ*S -- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S U RENT HO LY RATE. <br /> EHD Inspector: Recei d B Title: <br /> Irl UC {1 �� L <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev a/soli 2 <br /> ire c,o hQXM �i p e���ra�t Y-9j�a,� r V VC��� <br />