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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 Far: (209)468-3433 Web:w vv.sieov.ore/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> W G e 2 3 6 � <br /> Facility Address: Service Request#: <br /> v w <br /> Cl <br /> nA.rb?:a,�- � Oc. 0-7 i <br /> Onsite Service Technician's Name: ICC S vice Tec nicil nstall Certification#: Manufacturer Training: <br /> EL f-0 2 2 6 Qr,4 4Ga <br /> /2 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ ❑ mechanical Model: El 1 hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: El Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El mechanical Model: El 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El El <br /> mechanical Model: El 1 hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: <br /> El line test programmed ElCaldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> E] <br /> El fail safe Serial #: Elpsi <br /> El NA minutes <br /> sensor <br /> El positive shutdown Model: Secondary piping testing at: <br /> 7 <br /> ❑ ❑ fail safe Serial #: tet—Psi <br /> 11 NA L l; minutes Z/2 �v r <br /> sensor Secondary containment repairs for: <br /> F-1 El positive shutdown Model: ❑ UDC(s) <br /> El fail fail safe Serial #: Sump(s) aping <br /> El NA <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% X1 Corrosion protection VIe,,,, (� <br /> ❑ Overfill prevention (see LG letter 150-1) [11 Other: see below <br /> efe , cry l d AA f`v rt C ter. <br /> l , u I jLelv% Irdw'� - <br /> r lv (p m t L "q bc, <br /> THIS FACILITY IS SUBJECT TO REINSPEC ION AT ANY TIME AT EHD' C R ENT HOURLY RATE. <br /> EH speclor: Rece By: Tt <br /> V�^ <br /> EHD 23-04 <br /> Rev 06/22/07 <br />