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• SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3rd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Pax: (209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> ( Li! jl,;l -7lz -7 Jr <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: �� Y <br /> I�,ST4ZLFX i�S� <br /> -2 ? 7 7u - uT #9vILIf, I 9 <br /> SERVICE SERVICE <br /> cI 1 Leak detector Spill bucket El minimum 5 g4lon <br /> E2/ 1 mechanical Model��,It 1-1 El hour hydrostatic Elhicon TS-STS' <br /> ❑ electronic Serial#: ❑ Caldwell'System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El mechanical Model: <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> E] ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System El Other <br /> El line test programmed <br /> sensor, -Primary-piping,testrn gat: <br /> _ _ - - g. <br /> ❑ ❑ positive shutdown Model: El —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 /> F❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> L <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received BF Title: <br /> cvn 11-na <br />