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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.si¢ov.or ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility e. W L VC Inspection ueate' <br /> 31 g <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Servi a Technicianlinstaller Certification#: Manufat; rer raining: <br /> SERVICE SERVICE <br /> Leak detector D! `ti Spill bucket Wminimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: C well System KOthe�r <br /> Elline test pro ammed <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: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ 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 /> El Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> o„ 1 neS U An ff\ A c Ce Q rOr 1 � ��- <br /> j In 61y, 14fit/ lA l!e,7 ()e/--1 <br /> te� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> Inspeetor. Received By: Title: <br /> UPI �-- <br /> EHD 23-04 <br /> Rev 06/22/07 <br />