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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone: (204)468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM_ SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspcctlo Date: <br /> � -e v e4J I � 6 l <br /> Facility Address: Service Request#: <br /> Z G ai ns r G� ©C,(Lk— . S 2,O p <br /> Onsite Service Technician's Name: FCC Service Technician)Installer Certification#: Manufacturer Training: <br /> t)AVQ-, ire 1 �P o ©per <br /> SERVICE J Z SERVICE <br /> Leak detector _— Spill bucket /\0 minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial #: j Caldwell System gOther <br /> El 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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: l L1 I 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 /> ❑ falI safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> 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% ❑ I 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 /> f1 � t IJQ.r1 0 GoAWit, S r SUM %aJ. W1fLl. <br /> +�^ IL 4 N tj V (z,- S 1� wlv <br /> V L4 S -THIS FACILITY IS SUBJECT TO REINSPECTION AT AN TWE A HD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Re ved Title: <br /> v & <br /> 92 & l <br /> EHD 23-04 li ' l p T' 614% � <br /> Rev 06/22/07 <br />