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AQ U:`. <br /> �o.: ..c G SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> at <br /> N. I �I 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> c P,i Telephone: (209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> -Ate.o A - �CNG <br /> Facility Address: Service Request#: <br /> boo I IV Sil `z03 <br /> Onsite Service Technician's Name: ICC Service Technician/Ins alter Exp.Date: Manufacturer Training: <br /> 1 b-iQ -t ' UR- 0-• Q-1 VK- <br /> SERVICE <br /> -i <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test ro rammed E] Caldwell System ❑ Other <br /> Leak detector <br /> 11 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> F-1El❑ electronic Serial #: ❑ 1 hour hydrostatic ElIncon TS-STS <br /> 11 line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> ❑ 11positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑ fail safe Serial #: p <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 9500 Cold start of monitoring pane! <br /> ❑ Drop tube with mechanical overfill at 950/0 ❑ Corrosion protection <br /> j❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> lY1 This UST facility is APP OVECIto operate ❑ This UST facility is NOT APPROVED to operate <br /> /1 <br /> CLUe C--i Q- ` � e I <br /> Co- ) S — p Vi,4F' i <br /> io aA3nyboed iz, e-.(— <br /> ti <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In tor: O- Received By: Title: <br /> �s t <br /> VI <br /> nK�rp J` <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />