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o�quly . • <br /> ?•'•--��''•� SAN JOAQUIN COUNTY <br /> Q' ENVIRONMENTAL HEALTH DEPARTMENT <br /> N:I Imo' 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> '9'L lip R c?i <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 'Twno Gi C�uS 4 FvQ c4 ia-1 RE, l-1 <br /> Facility Address: Service Request#: <br /> LA e 52.10 SR c©-I-1 3 Ct <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SI1 �I r►k Sf�ll� -4 $q4 14� f 2 Cl r A V D (1125�1)f) <br /> �-,12 <br /> SERVICE SERVICE' <br /> Leak detector <br /> mechanical Model Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: El El1 hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ <br /> El electronic Serial: E] El hour hydrostatic El Incon TS-STS <br /> El line test ro rammed 11 Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> positive shutdown Model: ❑ psi <br /> El fall safe Serial #: <br /> ! <br /> minutes <br /> NA <br /> sensor Secondary containment testing f r: <br /> r- ❑ positive shutdown Model: UDC(s) _ Piping <br /> i <br /> ❑ fail safe Serial #: _ Sump(s) UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due by: <br /> ❑ C positive shutdown Model: (a Mop-it's CL-R6 i Iyst t.«yi*6 ti <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 /> 00SS <br /> 4sf o v' -+,U <br /> le i <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Tie: <br /> r <br /> f <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />