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PQu 11y <br /> �o. ,coG SAN JOAQUIN COUNTY <br /> Z ENVIRONMENTAL HEALTH DEPARTMENT <br /> .; 600 East Main Street, Stockton, CA 95202-3029 <br /> q v i4 Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.orq/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> !�" Nn 0 <br /> Facility Address: Service Request#: <br /> >-a-_G Trra�A, Tracy 0061-141 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> Gin `6 �cvNml cokes Sz�6 -u o I l 3 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial: ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test rogrammed 171 Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial#: <br /> El NA minutes <br /> ,07 r Secondary containment testing for: <br /> ❑ 'positive shutdown Model: `7 014'3$ 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 /> This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> (C41 tAN cqn5y fry- +4 <br /> J <br /> c <br /> c � <br /> THIS FACILITY IS SUBJECT TO REINSPECTj9N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins ctor: 1/gyp\��,cel B : Title- \ E�h, <br /> �/ / V <br /> L---a.— U :j I EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 ) / <br />