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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTHDEPARTME PT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www sieov.or�/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility N e: ` Inspection Date: <br /> .7� �- 0--�L <br /> Facility Address: Service Reques <br /> tI <br /> �� 0 M- <br /> Onsite Service Technician's Name: IC$ere caechnica;Insta!!yCertification#: N(pnufacturer Tr,ing:� I <br /> SERVICE SERVICE <br /> Leak detector n Spill bucket ❑ minimum 5 gallon <br /> mechanical Model: if ���"" ❑ 111 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: D ❑ 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#: O-AP 0-API ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: [ Primary <br /> ❑ 1 hour hydrostatic 11 Incon TS-STS <br /> 13 electronic Serial#: ❑ Caldwell System ❑ Other <br /> El line test ro ammed <br /> sensor piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: El _psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <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 /> PAM <br /> /)n <br /> 3-� C <br /> THIS F CIL TY IS SUBJECT TO REINSPECTION NY TIM T EHD'S CURRENT HOURLY RATE. <br /> EH p t r Receiv <br /> C1 <br /> EHD 23-04 <br /> Rev 06/22/07 <br />