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OAflUlty ,C\ <br /> ?•''--��''•p SAN.lOA0U1N COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> .: 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sdgov.org/ehd <br /> ttF4�t,/ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 9 11 cit •Take� 10 j 2-U I I(Al <br /> Facility Address: Service Request#: <br /> lSoil, N , ,ja6-'Tom CA q 6 30(p SIR 00-1(o387o CPddenchAm <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Exp.Date: Lnufacturer Training: <br /> J ame-S B\ckknE� `1 2c�tu U--YN 9 129 1201 -6 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> ;7 <br /> El electronic Serial #: ❑ ❑ 1 hour hydrostatic [IIncen TS-STS <br /> El line test programmed <br /> ❑ Caldwell System 11 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,77 El positive shutdown Model: Primary piping testing at: <br /> ❑ fail safe Serial #: ❑ psi <br /> ❑ NA minutes <br /> I sensor Secondary containment testing for: <br /> El positive shutdown Model: cct;�ik} 22- UDC(s) Piping <br /> El fail safe Serial #: '�'s CAI !;1? Sump(s) UST(s) <br /> ElNA <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑ positive shutdown Model 0&- (uo er Qo)-D <br /> ❑ fail safe Serial #: Note: ?lease 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% ❑ j Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 9590 ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> 4 This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> On s&AD i tis <br /> S 2t T-5 S�P . <br /> ' 2 t USG ar c� i - riyrn <br /> SIP ate Wcon AS, J ► <br /> �IlQ <br /> MMM U IAM S T Q spam s a r e�c-t e;tv ber �D. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> El iao(vx Florl d� TS~ Tzck ( )AVky1 <br /> EHD 23-04 UST SERVICE REQUEST INSPECTIr <br /> Rev 4/30/12 <br />