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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 Fax:(209)468-3433 Web:www_.sjgov.o&ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> C 0L� j� `7 v Z� a-7 <br /> Facility Address: Service Request#: <br /> �4" 510 s� oos28o-� <br /> Onsite Service Technician's Name: I C Service TechniciaiVInstaller Certification#: Manufacturer Training: I Z8 Z xr:) <br /> 4t <br /> X ,11C? <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> 1�4nechanical Model: V M 1. ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: 1,f02W200 ❑ 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 /> ❑ 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 /> ❑ 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: ❑ 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 /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> e-11--- t,our O Sr <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE.7ik- <br /> EHD Inspector: id By: Title: <br /> EHD 23-04 �' `S -Jr <br /> Rev 06/22/07 <br />