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f <br /> OPautN C <br /> SAN JOAQUIN COUNTY <br /> *NVIRONMENTAL HEALTH DEPARTMEN <br /> ®, 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.or /q ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Ald C219 <br /> Facility Address: Service Request#: <br /> 6 <br /> Onsite Service Techn clan Name: ICC Service TOhniclianjoltaller EXD.Date: Manufacturer Training: <br /> 4:4&OAA CIDWeZLI L�s 0-OrLo I L A- <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 <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro rammed ❑ Caldwell System ❑ Other <br /> sensor <br /> Primary piping testing at: <br /> ❑ positive shutdown Model: psi <br /> El ❑fail safe Serial #: ❑ mi <br /> ❑ NA minutes <br /> sensor Secondary 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 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 /> 9-This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> -- <br /> vPx'.'A-o lo <br /> -e <br /> VAv <br /> 61d Q)e -AIA <br /> UVC -M(Q -Ls do-.Qy\ Aue-4o )wv-z�vo� 6waKVQt04e- 9�m <br /> e <br /> THIS FACILITY IS SUBJECT TO REINSPEC AT ANY TIME AT EHD'S C RRENT HOURLY RATE. <br /> EHD Inspecto Rece' -A Title: <br /> OLV <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />