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oPgU I!y C <br /> 0 SAN JOAQUIN COUNTY <br /> c. a ENVIRONMENTAL HEALTH DEPARTMENT <br /> N _ 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sioov.org/ehd <br /> Ct'q <br /> hi O•Ra`P <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: In ction Date: <br /> Facility Address: ! Service Request#: fN k-Wil <br /> CA i7 2U 'Sft71019 <br /> nsi a Service Technician's Name: ICC Service Technicia nstaIler Exp.Date: Manufacturer Trai ng: <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 /> El ❑ mechanical Model: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment t sting f <br /> ❑ ❑ positive shutdown Model: UDC(s) 1 Piping <br /> ❑fail safe Serial CAD Sump(s) �- UST(s) <br /> ❑ NA <br /> sensor Testing for the above components are next due b <br /> ❑ <br /> El positive shutdown Model: ((( �� �fhD I ( �qI/J�� <br /> ❑fail safe Serial #: P 1 ",[x� �o� <br /> Note: Please be aware that 2°containment components are required'sLJ' test. uponT, <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 /> Ski 5' MO 75;PJC61*A > N <br /> on 2 <br /> 1� U4,vr i <br /> THIS FACILITY IS SUBJECT TO REINSPECT AT ANY TIM EHD'S CURRENT HOURLY RATE. <br /> EHD Inspe Rec ' ed : ' Title: <br /> LX, -4" 1 <br /> or <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />