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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.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> , ility Name: Inspection Dat <br /> Facility Address: Service 12eque t#: <br /> 1�y 2 1' S �:L113 I <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: [Manufacturer Training: <br /> kA t 1<a, <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: h Spill bucket '' m minimu5 gallon <br /> ❑ ❑ electronic Serial #: our hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ I hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> 01 ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell 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 /> F-1 ❑ fail safe Serial #: ❑ psi <br /> ❑ IIIA minutes <br /> sensor <br /> El positive shutdown Model: Secondary containment repairs for: <br /> El ❑ fail safe Serial #: ❑ UDC(s) Piping <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 /> /AA <br /> c <br /> Je 47 le) -<, e.r <br /> D -ol)Y <br /> THIS ACILITY IS SUBJECT TO REINSPECTION AT ANY TI AT EHD'S CURRENT HOURLY RATE. <br /> EH Spector: ! �^ Recei Title: <br /> v' l <br /> EHE 23-04 <br /> Rev 06/22/07 <br />