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�o. .co . SAN JOAQUIN COUNTY 16 <br /> Q ENVIRONMENTAL HEALTH DEPARTMENT <br /> hu j1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> \ c P'' Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.orgiehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date; <br /> Charm M-Atop � �li� � IISpoi� <br /> Facility Address: Service Request#: <br /> --6ce6 E. Harnmt r Ln. S�,(, -fin , CA 5 100-710? <br /> Onsite Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training; <br /> Aar v cl - 216 W1 0 Ri-tab 60wtS ed Le4jk- <br /> SERVICE SERVICE <br /> Leak detector <br /> E] mechanical Model: r, Spill bucket [I minimum 5 gallon <br /> 77 ❑ electronic Serial #: EJ El hour hydrostatic [IIncon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System [I Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> — I ❑ positive shutdown Model: <br /> ` <br /> fail' safe Serial #: psi 11 NA minutes <br /> sensor Secondar 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 950/-Q ❑ 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 /> ,, vv,� �S' v r�� of l in►► 11 '',S'tz+�.�� <br /> Of Orncl.-1' rTAir <br /> cfl,1-141 a h d VA 'r <br /> s Pry'i F-C- ' \ htAn t ri f`. A o NZ-- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receiv By: Title_--_ <br /> ci pynn it 1�1 ar o i rfr � <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />