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I <br /> 0.ul,N, fi <br /> ?� E•Co <br /> RECEIVED <br /> SAN.1OAQUIN COUNTY <br /> { ENVIRONMENTAL HEALTH DEPARTMENTJUN 16 201 <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 i <br /> Coq ;P Telephone:(209)468-3420 Fax:(209) 466-3433 Web:www.sigov.org/ehd <br /> . I <br /> <<i ... <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSP RT <br /> Facility Name: inspection Dans:I? <br /> Facility Address: M Service Request# <br /> 'N <br /> Onsite Service Techni Jan's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket 11 minimum 5 gallon <br /> ❑ ❑electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <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 /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> El El11fail safe Serial#: _ psi <br /> El NA minutes <br /> - sensor Secondary containment testing for: <br /> ❑ ❑ positive shutdown Model: UDC(s) Piping <br /> ❑fail safe Serial#: Sump(s) UST(s) <br /> El NA sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model: <br /> E]fail safe Serial#: <br /> Note: Please be aware that 2°containment components are required to be tested upon <br /> I] 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) 0, Other: see below <br /> I <br /> V1\ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> ` I r o -f,: C"4:1-- <br /> {%.. _ <br /> i w, <br /> t C <br /> t <br /> � ev f Gt .d'` :� 1 C1 s� <br /> tt <br /> TH S F,'CIE`17�Y ISS BJE.(,T TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. s <br /> EHD Insl4ectbr: f J A Received By. „.•.� Title: ✓ <br /> f � .•;-,f ftf0( ,�._„�° j,Yv`�;�„: °,.>�..,....,.L._ - ���Gl/I•..Q i-s ���'���'�•'., <br /> EHD 23-04 UST SERVICE REQU S7 INSPECTION REPORT <br /> R 13 <br /> ov 4/3 <br /> t'c6t 1 <br />