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OPQUtN C <br /> SAN JOAQUIN COUNTY <br /> c. -+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> " I�IVI ►: 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.segov.org/ehd <br /> 9�ilia <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name:� Inspection Date: <br /> [ / <br /> I zC.G' <br /> eI cam-i IC- 110 <br /> Facility Address: Service Request#: <br /> 11711 - P5rw17L k AA 10 MZ=,-A 00Z,/3!r1°[ <br /> Onsite Service Technician's Name: ICC S rwceTechnician/installer Exp.Date: Manufacturer Training: <br /> CAN CIE) J U S z( 1 z_ <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial: El El hour hydrostatic ❑ Incon TS-STS <br /> El 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 testro rammed <br /> jI sensor <br /> ❑ positive shutdown Model: U l y�130 -7l%�' Primary piping testing at: <br /> El❑ fail safe Serial#: Q psi <br /> + <br /> El NA � minutes <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 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 /> to This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> -✓t A2' Mf4,j c;, <br /> aiz5a Lr 'Lu ly—i <br /> f J A, <br /> rlti� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT AMY(TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rec iced By: Title: <br /> iv/? t ) f '�) <br /> EHD 23-04 <br /> Rev 10/06/10 i UST SERVICE REQUEST INSPECTION REPORT <br /> . I <br />