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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 Fax:(209)468-3433 Web:www,sigov.org/eh <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM( SERVICE REQ <br /> Facility Name: UEST INSPECTION REPORT <br /> r <br /> Inspecti Date: <br /> Facility Address: 1Ile <br /> � 06 <br /> �� r� t Service equest#: <br /> Onsite Service T'echnician's Name: I/,f ICC S— <br /> S vice Technician/1"stailer Certification#: <br /> hlanuFacturerTrainiog: <br /> It 2 o v c 11 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ ❑ mechanical Model: pill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: 7M04'ur hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed awell System ❑ Other <br /> Leak detector <br /> ❑ ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test pro ammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ CaldwelI System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ fail safe Serial #: ❑ psi <br /> ❑ NA minutes <br /> sensor <br /> ❑ ❑ positive shutdown Model: Secondary piping testing at: <br /> ❑ fail safe Serial #: ❑ psi <br /> ❑ NA minutes <br /> sensor <br /> ❑ positive shutdown Model: Secondary containment repairs for: <br /> ❑ fail safe <br /> Serial #: � 1 -f�OVDC(s) Piping <br /> ❑ NA Sumps) UST(s) <br /> TOEEE h mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> h mechanical overfill at 95% ❑ Corrosion protection <br /> rfill revention (see LG letter 150-1 <br /> ❑ Other: see below n.2r�u <br /> D 1nJ w <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHI� Spector: Re By: <br /> Title: <br /> V V '54 1 L< 7,-c -rf <br /> � v k a9 �r�sS� <br /> e zi o7 l r v �'�,�, v Q4)` 1 t� 0 FrVA,,�r/ 'f)",51— <br />