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SAN JOAQUIN COUNTY If <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone: (209)468-3420 Fax, (209)468-3433 Web: www Si o�V•°r�ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQS Date* <br /> Facility <br /> REPORT <br /> Facility Name: ? / �,l J j <br /> Ile <br /> Service eques #: <br /> Facility Address: jjj <br /> ICC Service TeUeh(/nicia nstal r Certifecation#: Manufacturer Training: ( +� <br /> Onsite Service Technician's Name: <br /> SERVICE SERVICE <br /> Leak detector Ead <br /> ucket ❑ minimum 5 gallon <br /> p ❑—mechanical Model: rostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ystem ❑ Other <br /> ❑ line test programmed <br /> Leak detector ucket ❑ minimum 5 gallon <br /> pmechanical Model: drostatic ❑ Incan TS-STS <br /> ❑ electronic Serial#: System ❑ Other <br /> ❑ line test proEammed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> Ell mechanical Model: El 1 hour hydrostatic ElIncon TS-STS <br /> electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> ensor TO <br /> mary piping testing at: <br /> ositive shutdown Model: psi <br /> 'Vfail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑❑ positive shutdown Model: p psi <br /> El ❑ fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ positive 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 /> El Overfill prevention(see LG letter 150-1} ElOther: see below <br /> c> UD <br /> 'lam <br /> tz <br /> r-e,Nr\4 'v r`!,211111111. n c v <br /> THIS FACILITY IS SUBJECT TO REI SPECTION AT ANY TIME AT EH 'S CURRENT H URLY RATE. <br /> ived By: <br /> E Spector: 1/ <br /> EHO 23-04 <br /> Rev 06122107 <br />