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SAN JOAQUIN COUNTY lift <br /> VIRONMENTAL HEALTH DEPARTMENTOW <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orglehd <br /> UNDER ROUND STORAGE TANK ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Na e: Inspection Date: <br /> s7sTL 6 ma�1 sfaIoV <br /> Facility Ad rens: Service Request#: <br /> S"-6S-3 �IC� <br /> Onsite 's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> T6 rrz4 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ r iechanical Model: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System 1:1 Other <br /> line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El El mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ C ectronic Serial#: ❑ Caldwell System ❑ Other <br /> line test rogrammed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: [E] ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ c lectronic Serial #: ❑ Caldwell System ❑ Other <br /> El line test proEarnmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ iositive shutdown Model: El —psi <br /> El ail safe Serial #: minutes <br /> ❑ 14A <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: El _psi <br /> ❑ ail safe Serial #: minutes <br /> ❑ qA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ ositive shutdown Model: El —UDC(s) Piping <br /> ❑ ail safe Serial #: Sump(s) UST(s) <br /> ❑ 14A <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Owrfill prevention(see LG letter 150-1) Other: see below <br /> oto .d vt�C4vwl 14 <br /> j 2 S — RsPE t 1�sPca <br /> — rLo <br /> �YwuU r s <br /> HIS FACILITY IS SUBJECT TO REIN .ECT ON T ANY TIME HD'S CURRENT HOURLY RATE. <br /> EHD Inspector R e Title: <br /> VV) % rl <br /> EHD 23-04 <br /> Rev 06/22/07 <br />