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SAN JOAQUIN COUNTY %-104 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sieov.org[ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> I .0(w <br /> Facility Address: Service Request#: <br /> 0 N. 4L1� v VV2of G19 Op531I) <br /> site Service Tee in i 's Name: ICC Service Technician/Installer Certification#: Mgno actu�ra ning: <br /> r� — <br /> SERVICE (�/ SERVICE <br /> Leak detector vq aaf 65 Spill bucket ❑ minimum 5 gallon <br /> X1` gmechanical Model: [A> 1400 ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> ❑ electronic Serial #: 0i0-1 k,;L 3 ❑ Caldwell System ❑ Other <br /> ❑ line test proEarnmed <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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <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 /> af �I <br /> P1443dkWe <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> W& ive Title: <br /> EHD 23-04 <br /> oe„nanoim <br />