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O Pp•U I N. <br /> SAN JOAQUIN COUNTY <br /> 2 �F, ENVIRONMENTAL HEALTH DEPARTMENT <br /> e: .y <br /> N 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax:(209) 468-3433 Web:www.slgov.org/ehd <br /> q�%FORa <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name; Inspection Dat : <br /> ry j-1126v, <br /> Facility Ad�2_0 <br /> ess: Service Request#: <br /> Ktff9rMn 1j-)) Lbd <br /> [o—ns!,t,e Service Technician's Name: ICC Service Technician/installer Exp.Date: Manufacturer Training: <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 <br /> ❑ mechanical Model Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial:: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ Caldwell System El Other <br /> Vq sensor <br /> El shutdown Model: �jrj �J � Primary piping testing at: <br /> El psi <br /> ❑ 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 /> 0❑ 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 /> Y tn-� X_r�,"� rinnikok, V J L( C�1 3 C _ <br /> a`- - S smsDr. <br /> v`1;�ev-s rt. r caunn! - VI;ZO w V\ -3 23 w <br /> �tf\t,IJl kfA,r\$ d, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> EHD 23-04 �� UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 4/30/12 <br />