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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 Fac:(209)468-3433 Web:www.sieov.orwehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: ` y ( Inspection ate: <br /> Facility Address: Service Request#: <br /> ' <br /> Onsite Service Technician's Name: ICC Service Technician/11n;[aller ificadon#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> 4?f mechanical Model: POL ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: 6 ❑ Caldwell System ❑ Other <br /> ❑ line test programmed Cb - Y� <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> 0 mechanical Model: ?,046� V i ❑ El hour hydrostatic 11Incon TS-STS <br /> ❑ electronic Serial#:QI 249951A ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ <br /> El electronic Serial#: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ 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: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <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 /> 1:1Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> tj <br /> s <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp� , r Received By: Title <br /> CC yo <br /> EHD 23-04 <br /> Rev 06/22/07 <br />