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%001 ENVIRONMENTAL <br /> JOAQUIN COUNTY � <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wwwsieov.or ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> 3 w N' Sf- 0os3111e <br /> i <br /> Onsite Service Tech cian's Name: ICC ServiceTechnici�nlinnsstt�all�er Certification#: nufacturer Training: <br /> SERVICE SERVICE <br /> 191 1 Leak detector Vst-pa✓l tis Spill bucket ❑ minimum 5 gallon <br /> ;"mechanical Model: LD?�GrJ ❑ El hour hydrostatic F-1 Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test ro ammed <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 /> El ❑ 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 #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: El _psi <br /> F-1failsafe 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 /> mp VIM i1YY1'Ydj 'W/ <br /> Ml <br /> THIS FAILITY IS SUBJECT T RE SPEC ION AT AN IME AT EHD'S CURRENT HOURLY RATE. <br /> Ins ect eceiv d B Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />