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P4utN <br /> .coG SAN JOAQUIN COUNTY <br /> 2: <br /> ¢' ya ENVIRONMENTAL HEALTH DEPARTMENT <br /> N. `.. 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sagov.org/ehd <br /> C9C110R�;P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Ake ov, (wl 41-7111 <br /> Facility Address: Service Request M <br /> 1711 mct vtIct ac , YNa�vi�-eca 9�0D622-o3 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Jo ✓fL ��c !C C $P S007 00 j 7/7 7 - /972- <br /> SERVICE <br /> SERVICE SERVICE <br /> _ Leak detector Spill bucket ❑ minimum 5 gallon <br /> Urnechanical Model: Um I qui LD 2,000 ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: r 00514017 <br /> ❑ line test programmed <br /> El Caldwell System El 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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ 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 be aware that 20 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 ❑ This UST facility is NOT APPROVED to operate <br /> -11 (R a.k 3 <br /> 04-0 AV az 110 Le <br /> U If <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> EHD Inspector: -7 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />