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SAN JOAQUIN COUNTY ' <br /> ENVIRONMENTAL HEALTH DEPARTMEN'I--- <br /> 304 East Weber Avenue,P Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fac:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 614 k- i S -71 X0108 <br /> Facility Address: Service Request#: <br /> [(- cOo C mP*(Pcls 51zo zhl <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> L)) Nc.E uc-2eL Lk T, <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model �9I Spill bucket [minimum 5 gallon <br /> El ❑ electronic Serial : '�1 hour hydrostatic Ellion TS-STS <br /> ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> ❑ <br /> El electronic Serial#: 11 111 hour hydrostatic ❑ Incon TS-STS <br /> 11 Caldwell System ❑ Other <br /> 11 line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El El1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: El Caldwell System ElOther <br /> ❑ line test programmed <br /> sensor <br /> ❑ ❑ positive shutdown Model: Primary piping testing at: <br /> El <br /> ❑ fail safe Serial#: p <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor <br /> ❑ Secondary containment <br /> t repairs for: <br /> ❑ ❑ positive shutdown Model: LTDPiping <br /> ❑ fail safe Serial#: i <br /> Sumps) 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 /> A — s <br /> V S ,< <br /> c Q d <br /> a .: V <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY IME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: _ � '� , ^ Ree d By: Title: <br /> vV .L_ <br /> EHD 23-04 <br /> 1/3/07 <br />