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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.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 1zJ� L S 11 ±IcA <br /> Facility Address: C L Servic Request#: <br /> 6W?o r Jr l-',4"D SIwVs�;7wo <br /> Onsite rviice Technician's Name: U ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> Ivw bl' V12— <br /> SERVICE <br /> SERVICE SERVICE <br /> �L 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 /> 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 /> /tee I,r sensor <br /> positive shutdown Model: U2 Primary piping testing at: <br /> 12-fail safe Serial #: 3a? ❑ psi <br /> 1-1 NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> 1:1 fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> 1:1 fail safe Serial #: p g <br /> 1:1 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 (see1 LG letter 150-1) ❑ Other: see below <br /> ':F1N <r <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> FEHDInspector Received By: Title- <br /> EHD 23-04 <br /> ae.,nanom> <br />