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o.?'•q�I'y•.c <br /> SAN JOAQUIN COUNTY <br /> Q' �+ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> f ,.P Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.sigov.org/ehd <br /> FORS` <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> i - 3�a a q-3 -x( <br /> Facility Address: Service Request#: <br /> Lfq L4 L Q at CA 52AcOi u S 3�:I- <br /> Onsite Service Technician's Name: ICC Ser ice Technician/installer Exp.Date: Manufacturer Training: <br /> n 5 - --tom 6 j(A -20 PW - fid-12)-X0 VP-- <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial: ❑ El hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial: El El hour hydrostatic El Incon TS-STS <br /> El line test ro rammed El Caldwell System ❑ Other <br /> sensor <br /> El El shutdown Model: ❑ Primary piping testing at: <br /> si <br /> El 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 /> ❑ j Drop tube with mechanical overfill at 95% ❑ j 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 /> lk This UST facility is APPROVED to operate ❑ This UST facility is NOT APPROVED to operate <br /> 0 mli4o �0 C6�kW tA— -W-Le-L, Q-,11 VVU(ak- 3C-0 -kC-V'- M d-.LA 1,0 S <br /> �� - -� <br /> " I oor I ' <br /> OLA n u ctir sE �s n • ` o ria <br /> � � a <br /> i Q VQXI <br /> L- Ur l,a cacurms oemr to rp Oh <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TI AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> � �- rn •Tec0NIL VA <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />