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SAN JOAQUIN COUNTY <br /> VIRONMENTAL 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 <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE RE UEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> GRcce k <br /> Facility Address: Service Request#: <br /> [64--70 C�rmekjDGEr S1?00's-q'2 � <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> Flzemcic I oPw -NA(MIAl/n V6eiPY&-) <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: ❑ El hour hydrostatic El Incon TS-STS <br /> El electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System L1 Other <br /> El 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: ❑ psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ si <br /> ❑ fail safe Serial #: p <br /> 11 NA minutes <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: Sump(s) 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 /> Sf/ t- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />