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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fier:(209)468-3433 Web:www.sjgov.orglehd <br /> UNDERGROUND S'T'ORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility[Mame: Inspectio Date: <br /> 1-e very -7 0 <br /> Facility Address: Service Request#: <br /> �S Comet j 'tj 6 t u� gl j, 91rz DO Y-yoo� <br /> onsite Service Technician's Name: I Se lee Technician/installer Certification#: Manufacturer Training: <br /> 4 <br /> 3-e s-S42-', dlL.r n 6 I <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> El ❑ ❑ I hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ Iine test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ I hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El mechanical Model: El 1 hour hydrostatic 0 Incon TS-STS <br /> 1:1 electronic Serial#: El Caldwell System L7 Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> El NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ positive shutdown Model: El psi <br /> fail safe Serial #: <br /> ❑ NA minutes <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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EH17[ ector: Re civcd l"iil <br /> N <br /> E=HD 23-04 <br /> Rev 06/22/07 <br />