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SAN JOAQUIN COUNTY <br /> WNVIRONMENTAL HEALTH DEPARTMEN*. <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone.(209)468-3420 Fax: (209)468-3433 Web: www.sigov.org/eh <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility name: Inspection Date: <br /> Cb LD 12 �13 �U� <br /> Facility address: Service request number: <br /> (o I(0 F. L�Ar�rly- C N. Sac L' •.l Sz 66 -/ ('6 y8 <br /> Name of Service Technician performing tests: ICC Service Technician/Installer certification#: Manufacturer training: <br /> SERVICE SERVICE <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 /> F-1 ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> F-1 <br /> El electronic Serial #: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor 214 <br /> positive shutdown Model:85-7 b 90 - 12 Primary piping testing at: <br /> psi <br /> Mail safe Serial #: E,ipt ❑ minutes <br /> ❑ NA <br /> sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> ❑ ❑ fail safe Serial #: ❑ psi <br /> ❑ NA minutes <br /> sensor <br /> El positive shutdown Model: Secondary containment repairs for: <br /> ❑ <br /> ❑ fail 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 /> ❑ Ovckfill prevention (see LG letter 150-1) ❑ Other: see below <br /> n ort i .1 " TLA L 2 r D v r LAI P(�f <br /> l cq H <br /> xtib 0'4'S d'o.. t AAd i.—onAf <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TI E EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect o Reived Tit�le:q. yy// <br />