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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.sjeov.org ehd <br /> UNDERGROUND STORAGE TANK ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Insp ' n Date <br /> ar C ieurvnJ 2 ect /n/7b <br /> Facility Address: Service Request#: <br /> 0 W , C.In-a�� �- W� S4-o& 16{011l 4200S (0072 <br /> Onsite Service Technician's Name: ICC Service Technicion/Installer Certification#: Manufacturer Training: <br /> Ere NrLt IX 6&U 121110 &12 5 101 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 13 minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 11 electronic Serial #: <br /> ❑ line test programmed ElCaldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> 1-1 electronic Serial #: El 1 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ El hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> El positive shutdown Model:El fail safe Serial #: El Primary <br /> ❑ NA minutes <br /> sensor <br /> ❑ positive shutdown Model: Secondary Y pI In testing at: to¢ c <br /> ❑ ❑ fail safe Serial #: 3, S psi PO6} 601\Cr-e4q-j pvv1. <br /> ❑ NA 4 D minutes <br /> :US <br /> sensor <br /> El positive shutdown Model: Secondary containment repairs for: <br /> ❑ <br /> ❑ fail safe Serial#: E-1 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 /> ( -k, Uor-T S¢(oNQq 6D1)4%4M&V � re 11- l eS'e-U <br /> rot)U& Ina. • "r¢ k KMS 4r4-t� kk j; o?rR do <br /> k 1^ 1-1 LVA42,0-bv\ �-O (vn4e&k(/-\ <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector. ReceiG d By Title: <br /> Title: —.0� L <br /> t C <br /> EHD 23-04 <br /> Rev 06/22/07 <br />