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SAN JOAQUIN COUNTY <br /> �%/ ENVIRONMENTAL HEALTH DEPARTME* <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facili Insp tion Date: <br /> & " l�3.a� <br /> Faci7 dress: Service Request#: <br /> Sr-00 5- 122 (&+0 SY 2q <br /> Onsi a Servi T hni 'an's Name: ICC Service TechniciaNinstaller Certific tion#: Manufacturer Training: <br /> 211 to vim►, <br /> SERVICE SERVICE <br /> Leak detector <br /> ElTR K <br /> mechanical Model: � Splll bucket inimum 5 gallon <br /> 01 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System El Other <br /> El line test ro ed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> ❑ NA minutes <br /> sensor $9' N?S+r <br /> positive shutdown Model: Secondary piping testing at: <br /> fail safe Serial #: ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment repairs for: <br /> ❑ positive shutdown Model: ❑ 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) ❑I Other: see below <br /> GL1/ t o e Z <br /> THIS FACILITY IS SUBJEC REINSPE NAT IME AT EH 'S C RRENT HOURLY RATE. <br /> meTitl;: <br /> I/ l <br /> EHD 23-04 <br /> Rev 0&22/07 <br />