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O.4'J <br /> '?• --+E� '•p`, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> N: I < <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd <br /> �tt`oRN, <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: (('' ,,,� Ijnspection Date: <br /> -A 9W / ADA 0 S SW�(J� to -(e4-q -.-1019 <br /> Facility Address: Service Request#: <br /> boo"I N I a T � sm"03 to <br /> Onsite Service Technician's Name: 15�op ICC Service Technician/Installer Exp.Date: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial #: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed 11 Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> El positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑ fail safe Serial #: p <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 /> ❑ 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°0 ❑ Cold start of monitoring panel <br /> Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> Overfill prevention (see LG letter 150-1) [N.Other: see below <br /> ❑ This UST facility is APPROVED to operate This USTf cility 's NO APPROVED to operate <br /> V\10JZJ <br /> � i \ ' � 2 (��Q1� Y9✓'iC� <br /> NClf� <br /> A5 <br /> OL 0 W AAAk R 2 --w er <br /> 'blr wC <br /> '3 a11 bii <br /> OA Z1- (0 4111 lalk'L+ -A 11) <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CU RENT HOURLY RATE. <br /> EHD Inspector: Received By: Title <br /> rJ� i C' <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 1 (0.� 2 <br />