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SAN JOAQUIN COUNTY <br /> ;ENVIRONMENTAL HEAL'T'H DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sigov.orgfehc! <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: InspectDate: <br /> i n <br /> Facility Address: Service Request#: <br /> n 35 <br /> Onsite Service Technician's Name: ICC ServiceTechnician/[ taller Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 11 minimum S gallon <br /> 9mechanical Madel:�l -- 0 � ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System El Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El mechanical Model: ❑ F-1I hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: <br /> ❑ Tine test programmed ❑ Caldwell System El Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: ❑ ❑ I hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> El positive shutdown Model: <br /> El ❑ fail safe Serial #: 1:1psi <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> 11 fail safe Serial #: <br /> NA minutes <br /> sensor Secondary containment repairs for: <br /> El El positive shutdown Model: Piping <br /> El fail safe Serial #: ® SuO mps} 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 /> L11"h W <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT HD'S CURRENT HOURLY RATE, <br /> EHD Inspector: Received St <br /> Title <br /> EHD 23-04 <br /> o_..ncrnnrn-r <br />