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oPp• u i N• •.0 <br /> ° SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> a <br /> ti <br /> N'. . 1868 East Hazelton Avenue , Stockton , CA 95205- 6232 <br /> Telephone: (209 ) 468-3420 Fax: (209) 468 - 3433 Web: www . slaov . org/ehd <br /> FOR�`P <br /> UNDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection DateLl <br /> V Ay\j co LA L DS / <br /> Facility Address : Ser ' e Requ st #: <br /> X33 (zp a41 "1317 <br /> Onsite Service Technician ' s Name : ICC Service Technician/ y�sllgr Exp. Date : Manufacturer Training : /f� I <br /> L l� L r� � � f = l� f ec s o <br /> / f I/an ,� v <br /> SERVICE SERVICE <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 /> Leak detector Z <br /> ❑ mechanical Model : 'Spill bucket Vminimum 5 gallon <br /> ❑ ❑ electronic Serial # : 0 1 hour hydrostatic ❑ Incon TS- STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at : . <br /> ElElpositive shutdown Model : El psi <br /> El fail safe Serial # : <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 % ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95 % ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150 - 1 ) ❑ Other: see below <br /> ❑ This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> Ar& : 7� c C , 4, Cam, n, r�Gecv�c fc IL41j <br /> bSM IA2C( <br /> Sip J�A�c JI� AIL L C1 4C41 <br /> G I�2cQ l.c ect;. <br /> Cti�i aI Ctf h cw+.(,( � A +ter 1/,z <br /> 4 C9C i , 1 <br /> r' <br /> THIS FACILITY IS SUBJE T TO REINSPECTION AT ANY TIME AT EHD S CURRENT HOURLY RATE . <br /> EH Inspector: Received By: _ - Title : <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />