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SAN JOAQUIN COUNTY <br /> ONVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.ore/ehd <br /> UNDER sROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Noe: Inspection Date: <br /> S d a /W-�Ooer SIWOg, <br /> Facility Add ess: Service Request#: <br /> -70 f4-y, 90a,) FfUl-CZ CA---r S fz- 19/ <br /> Onsite Semi a Technician's Name: ICC Service Technician/Installer Certification#: <br /> l de Lfu Manufacturer Training: <br /> ✓� I::p <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ e ectronic Serial#: ❑ Caldwell System ❑ Other <br /> line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ [I 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 /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ e ectronic Serial#: ❑ Caldwell System E] 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 /> ❑ ii it 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 /> ❑ A <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ 1 Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ <br /> Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> cel 12 s a11Awx e6.4e� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> FHD Inspector: ( Received By: Title: <br /> /l, • /� / /? <br /> EHD 23-04 <br /> Rev 06/22/07 <br />