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uV it <br /> SAN JOAQUIN COUNTY <br /> T7. X ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax. (209) 468-3433 Web:www.siaov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> • <br /> Facility Ad ss: L Service Request <br /> Onsite Service Technician's Name: ICC Service Te6hnician/ifistaller Exp.Date: Manufacturer Training: <br /> ;Site 7777---7 <br /> G-5—are-4-XII-1 I I - uce Pd <br /> SERVICE SERVICE <br /> Leak detector Spill bucket D minimum 5 gallon <br /> El 0 mechanical Model: El El 1 hour hydrostatic E] Incon TS-STS <br /> 0 electronic Serial #: 0 Caldwell System El Other <br /> El line test programmed <br /> — Leak detector <br /> 0 mechanical Model: Spill bucket 0 minimum 5 gallon <br /> ❑ El electronic Serial #: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 line test programmed El Caldwell System 0 Other <br /> — sensor Primary piping testing at: <br /> F-1 0 positive shutdown Model: <br /> 0 fail safe Serial #: M psi <br /> 0 NA .minutes <br /> - sensor Second containment testing for: <br /> 0 positive shutdown Model: <br /> El 0 fail safe Serial#: UDC(s) Piping <br /> 0 NA Sump(s) UST(s) <br /> - sensor Testing for the above components are next due by: <br /> El 0 positive shutdown Model: WAL J 3 <br /> 0 fail safe Serial#: A <br /> Not Please be aware that 2o containment components are required to be tested upon <br /> 0 NA installation,6 months after, <br /> and every 36 months thereafter. <br /> 1771 —Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> 0 Drop tube with mechanical overfill at 95% El Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) El Other: see below <br /> k-/ <br /> El This UST facility is APPROVED to operate This I 1QT fac <br /> 121W _ is NOT APPROVED to operate <br /> (nu- W- <br /> o9j&jvL -24 R (or e-ouAvolea*)+ <br /> / <br /> VIC INCOIS) \0o-v, <br /> CLIO --kj) <br /> "AA CM�vk(?4— 11 Oyl ' <br /> AW4V-'I L44 Nek. <br /> i P rov , Lkc*�e_�k- cAC, tA v�i eA* <br /> Ae CG <br /> THIS FACILITY IS SUBJECT TO REINSPEC N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: YV\ Receive Title: <br /> aip I <br /> EFID 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />