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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.sieov.ore/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspect. n Date <br /> M- IQA C�•eur-onj 2 T 7b <br /> Facility Address: Service Request#: <br /> 0 8 W , 4�} 1�- �� �-I'DGlL�-vJ S2DUS (o07Z <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> Em— r` Ito zSl0'9 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> ❑ fail safe Serial#: Elpsi <br /> 11 NA minutes <br /> sensor Secondary piping testing at: b)es,/(. <br /> ❑ ❑ positive shutdown Model: 3, <br /> El fail safe Serial #: S psi <br /> P081- 601\C1`449-) PPLA-. <br /> ❑ NA ��minutes <br /> .U8 <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) UST(s) <br /> ❑ NA <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 /> (1Si�G UOr1 Se(ON0q C#1)4illWV }— OA l^e li— njefe-�_ <br /> Pro W41 Ine "r¢ �vflS far I� r,$ y r r¢ v dnr <br /> 1p,ki 1Lld `� � /•s��Ar (1y i(9`/� °e CG0�) <br /> 3, Y Si po^ 67 M X1.1 , <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD spec[oc Rece' By: Title:rt..rr.C, <br /> IC <br /> EHD 23-04 <br /> Rev 06/22/07 <br />