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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/e&d <br /> UNDERGROUND STORAGE TANK ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> an& k- 6(3olog <br /> Facility Address: Service Request#: <br /> 1 W SQ00-5,42-01-�► <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> Rtayx. L gejoa S3138n — UT OPw 3-7gO <br /> SERVICE SERVICE <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 /> ❑ <br /> El mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> F-1 electronic Serial#: <br /> ❑ line test programmed ElCaldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ El hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System ❑ Other <br /> ❑ line test ro ammed <br /> sensor <br /> El psi <br /> positive shutdown Model: ❑ Primary piping testing at: <br /> El fail safe Serial #: p <br /> ❑ NA minutes <br /> sensor Second piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ si p p g g <br /> ❑ fail safe Serial #: p <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: <br /> El 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 95n/o OW Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> Pelf -t�'ar <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD inspector: Receiv By: �- Title: <br /> AIM P-&,, � <br /> EHD 23-04 <br /> Rev 06/22/07 <br />