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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.s*gov.oro/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> <I <br /> Facility Address:2 6S N Service Request 4h <br /> idnr f L-0�1- I <br /> _ _r� <br /> Cinque Service Tecooician),Narrip: ICC Servicb Technici7nstaller Exp.Date: Manufacturer Training, <br /> L <br /> &4 7 <br /> SRVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El 0 mechanical Model: El 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial <br /> 0 line test 0 Caldwell System El Other <br /> programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> 1771 0 mechanical Model: El 0 1 hour hydrostatic El Incon TS-STS <br /> 0 electronic Serial <br /> 0 line test 0 Caldwell System El Other <br /> programmed <br /> sensor Primary piping testing at: <br /> 11 0 positive shutdown Model: El —psi <br /> 0 fail safe Serial <br /> 0 NA minutes <br /> sensor Secondary containment testing for: <br /> El 0 positive shutdown Model: UDC(s) Piping <br /> 0 fail safe Serial#: Sump(s) UST(s) <br /> El NA sensor ❑ Testing for the above components are next due by: <br /> El 0 positive shutdown Model: <br /> 0 fail safe Serial#: Note: Please be aware that 2*containment components are required to be tested upon <br /> El NA installation,6 months after,and every 36 months thereafter. <br /> D Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> El Drop tube with mechanical overfill at 95% Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) El I Other: see below <br /> El This UST facility is APPROVED to operate This UST facility is NOT APPROVED to <br /> LLI �M�K AV- =S7 <br /> 4, f 4- -4/ <br /> THIS FACILITY IS SURJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> Tit <br /> EHD Inspector: R ved By: Title: <br /> 1) <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 C/ <br />