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SAN JOAQUIN COUNTY <br /> '4./ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:w)viK.sjgov.org/e <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspect' Date• <br /> eas coM � L �c, � ala <br /> Facility Address: IService Itecluest#: <br /> 2113 F , qr i OSA Q;) , �hlcXh 52005 L1316 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> ccs op(&/ <br /> SERVICE SERVICE <br /> Leak detector c S <br /> ❑ mechanical Model: �I Spill bucket ❑ minimum 5 gallon <br /> ❑ El El hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: ❑ Caldwell System �Other <br /> ❑ line test ro 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: ❑ si <br /> ❑ fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Pi <br /> El fail safe Serial #: ( � 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% )d Corrosion protection <br /> ❑rOverfill prevention(see LG letter 150-1) ❑ Other: see below <br /> n S i V corr0SI cn tlx <br /> Y b( blia I <br /> F <br /> 46 C'n <br /> THIS FACILITY IS SUBJECT TO REINSPEC ION ATA T)1MEAT EHD'S CURRENT HOURLY RATE. <br /> EH Spector: Remo By: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />