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oAqulnf O <br /> � �'E •o� SAN aIOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N 600 East Main Street, Stockton, CA 95202-3029 <br /> ;P Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> A�1PORa` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> L4UvvMjy-C NAf rmA 61612-D I <br /> Facility Ad r ss: Service Request#: <br /> 3� 4mL W[ovj P4 — 006 ?�52 <br /> Onsite Service Technician's Name: ICC Service echnician/In taller Exp.Date: Manufacturer Training: <br /> 2� V12- <br /> SERVICE SERVICE <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 /> 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 /> El fail safe Serial#: <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 I 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 /> V. bard 4 <br /> 112, fDC <br /> THIS FACILITY IS SUBJECT TO REINSPECTION ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In ct Received By: Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 10/06/10 <br />