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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3re Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Pax:(209)468-3433 Web:WWw.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK ST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: lnspocfivn bate: <br /> npVCl 'O `.o i�v,d t, MA/I <br /> r <br /> Facility Address= service Request#: <br /> Onsite Service Technician's Name. ICC Service Technician/Installer Certification#; Manufacturer Training: <br /> Uri ~C <br /> SERVICE SERVICE <br /> Leak detector +':f 1_7T70 <br /> Spill bucket ❑ minimum 5 gallon <br /> 19 mechanical Model: c 'r P' A14 El ❑ 1 hour hydrostatic ElTncon TS-STS <br /> El electronic Serial#: GCS i IU �V ❑ Caldwell System ❑ Other <br /> ❑ line test ro ed <br /> Leak detector Spill bucket ❑ minimums gallon <br /> El mechanical Model: <br /> � <br /> El electronic Serial#: El 1 hour hydrostatic ElTncon TS-STS <br /> 11 line test programmed <br /> C] Caldwell System 13 Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum$gallon <br /> : <br /> ❑ ❑ electronic Serial El111 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ si <br /> ❑ fail safe Serial#: p <br /> 11 NA minutes <br /> sensor <br /> ❑positive shutdown Model: Secondary piping testing at: <br /> ❑ El❑ fail safe Serial#: psi <br /> minutes <br /> ❑NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: p UDC(s) Pi in <br /> ❑ fail safe Serial#: ( ) p g <br /> ❑NA sump(s) UST(s) <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 /> vj M��GG'n�, C.A (. n ."� (- o c? <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY WE. <br /> tHD Ipssector: I ReceivfdIlr. / Title: <br /> EHD 23-04 <br /> SOO d 801HS860ZI ON %Vd 'HM SS31 x03 9003 AV 01 :LO QHM/L00Z/WM <br />