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SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N.ba 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> CiFOfxN' <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> ` L. sQXv G ja .,2,o/s <br /> Faci ty Address: Service Request#: <br /> 42-0 LO "illiliervi "q I �lt' 51P�Ooq 26 33 <br /> Onsite Service Technician's Name: ICC Service Technician/Insta ler Ex ate: Manufacturer Training: <br /> J m a.�o a 1,9oiv I- - I <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial #: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> [I line test programmed <br /> El 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 /> positive shutdown Model: ❑ Primary testing at: <br /> 11 El <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment testin for: <br /> ❑ <br /> El positive shutdown Model: UDC(S) <br /> Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <br /> sensor A Testing for the abovle� components are next due by: <br /> ❑ El positive shutdown Model: nyrl v� �LL(S-`t 1- <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 LIS letter 150-1) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to operate <br /> v►Si 4 e �o �/ zio q- V-)2- a� 2-cj <br /> la hs J S 1� � .�C rQ r 0 0 <br /> Q ' - CA'l A M01 51.0 WlO,,,-cx ���' �w� `jam �t ecl <br /> V\,0V r "10+; sIf cut kS )e �s . <br /> raAp- Ov`vvibt �a-,qay&0L-LC;, va�� wa,�Ae, A A r- wa,� " a-J cl eik <br /> THIS VACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S Cl RENT HOURLY RATE. <br /> EHD Inspect��'�^,,. Re iv By' Title: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />