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0?+4 ..! N c 6 6 �E�' •Pa SAN JOAQUIN COUNTY Qr�— Za y ` ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Onsite Service Technician's Name: Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd 9�hio ❑ UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: .Trm�A NA-YI) Inspection Date: Facility Address: Nr_ EA V_� Service (RIe71quest #: 0 & q-41 q Onsite Service Technician's Name: ICC Service Technician/Installer Exp. Date: t Manufacturer Training: V t Ui►z�✓a l SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed ❑ Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ ❑ NA ❑ sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA ❑ Drop tube with mechanical overfill at 95% ❑ Drop tube with mechanical overfill at 95% ❑ Overfill prevention (see LG letter 150-1) This UST facility is APPROVED to operate r/.1 t� ��MO� AI L1 �_ i�Mr&I.A•AI SERVICE Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS ❑ Caldwell System ❑ Other Spill bucket ❑ minimum 5 gallon ❑ ❑ 1 hour hydrostatic ❑ Incon TS -STS Received c y: a . �. � ' ❑ Caldwell System ❑ Other Primary piping testing at: ❑ psi minutes Secondary containment testing for: UDC(s) Piping Sump(s) UST(s) ❑ Testing for the above components are next due by: Note: Please be aware that 2° containment components are required to be tested upon installation, 6 months after, and every 36 months thereafter. Cold start of monitoring panel ❑ Corrosion protection ❑ Other: see below ❑ This UST facility is NOT APPROVED to operate ■ , A. �I► 111111 �.R /.�... �i /. r • .,. .W _ �..■■ .. e._.� _lm 1111 IVIOAMVWIUS�A W. A..� . ► Received c y: a . �. � ' Title- Ula EHD 23-04 v UST SERVICE REQUEST INSPECTION REPORT Rev 10/06/10