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Uve 11 <br /> °Aa 'ao <br /> SAN JOAQUIN COUNTY <br /> 6 <br /> a: -+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> > � 1868 East Hazelton Avenue , Stockton , CA 95205 - 6232 <br /> (#1 — �P <br /> • <br /> Telephone : ( 209 ) 46 & 3420 Fax: ( 209 ) 468 - 3433 Web: www . sjgov . or /e ca <br /> q �lFOR � <br /> UI`IDERGROUND STORAGE TANK ( UST) PROGRAM SERVICE REQU5111 <br /> INSPECTION REPORT <br /> Facility Name : In ection Date : <br /> Aon JO � <br /> Facility Address : Service Req st # : <br /> X00 roc ' nC., <br /> Onsite Service Technician ' s Name : ICC Service Tech nicianllnstalI r Exp . D te : Manufacturer Training : <br /> 1 IVA . <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 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 /> El El shutdown Model : ❑ Primary testing at : <br /> si <br /> ❑ fail safe Serial # : minutes <br /> ❑ NA <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 20 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 % D Corrosion protection <br /> ❑ Overfill prevention ( see LG letter 150- 1 ) Other: see below Sic S �� <br /> ❑ This UST facility is APPROVED to operate This UST facility is NOT APPROVED to opera e <br /> 4o d6Ll aiairoydion iQ C1 :Hc r: <br /> o V1 Mk <br /> C ULA Q <br /> CP S /n c Les <br /> L 02 <br /> Q <br /> THIS FACILITY IS SUBJECT TO REINS ECT N AT Y TIME AT EHD ' S CURRENT HOURLY RATE . <br /> EHD Inspect R ceived y : Titl . <br /> � rte` <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />