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SAN JOAQUIN COUNTY <br /> WNVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.or <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection date: <br /> � slmN t-S kigorj bepT. ,5 2,1 o e <br /> Facility Address: Service Request#: <br /> +S 1*Ftlz-?6121 SAI'( s sR-oa S3 0s 7 <br /> Onsite Service Technician's Name: ICC Service Tech nicianllnstalier Certification#: Manufacturer Training: <br /> t N' r C U�fi C�Sv <br /> 08 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> electronic Serial #: <br /> El line testroammed ❑ 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 ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial 9: ❑ ❑ I hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> El positive shutdown Model: Primary piping testing at: <br /> F-1 ❑ fail safe Serial #: (�,psi <br /> ❑ NA _(moi minutes <br /> sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> ❑ <br /> El fail safe Serial 4: ❑ psi <br /> ❑ NA minutes <br /> sensor <br /> ❑ positive shutdown Model: Secondary containment repairs for: <br /> ❑ Elfail 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 /> THIS FACILITY IS SUBJECT TO REINS TION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD fnspgctar. Recei�13y: /' Title: <br /> M n Int e[ 3 yl <br /> EHD 23-04 <br /> Rev 06/22107 <br />