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*, SAN JOAQUIN COUNTY <br /> ' ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgov.org/chd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> y & 7/Z 6 07 <br /> Facility Address: Service Request#: <br /> '3 :W aosi6 -70 <br /> Onsite Service Technician's Name: ICC Service Techuician/Installer Certification#: NWufactiAr r Train' g: <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 1-1 <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test 2rogramined ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> E ❑ electronic Serial #: ❑ 111 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> dpositive shutdown Model: u(-s Primary piping testing at: <br /> El fail safe Serial#: 12o P-7i"A— ❑ psI <br /> ❑ NAZ4 U I 15 r� minutes <br /> sensor Secondary piping testing at: <br /> ❑ positive shutdown Model: <br /> ❑ <br /> 11 fail safe Serial#: Elpsi <br /> ❑ NA minutes <br /> sensor Secondary containment repairs for: <br /> E_ ❑ positive shutdown Model: p UDC(s) Piping <br /> ❑ fail safe Serial #: <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 /> THIS FACILITY IS SUBJECT TO REINSPECTI N T TME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: I Reg v Title: <br />