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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.sogov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> v <br /> FacilityAddress: Se"ce ecluest# <br /> Z'/CL/-C l �C��� btu -5a-u>a532-�s <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: 7 <br /> Acr•(� `� —`-f- 13 �'i.� �� �tr 9 <br /> -I2 31 Apt <br /> SERVICE SERVICE <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 /> Leak detector kAjQ 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: El _psi <br /> ❑ fail safe Serial#: minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: S psi t„/, <br /> ❑ fail safe Serial #: �Q minutes 7' <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 /> 01 overfill prevention(see' LG letter 150-1) 11 Other: see below <br /> 1iwo A -PX Lie <br /> l G- Is,- -1-0 bras PJs,� <br /> n, A 10 <br /> G c (Yl • rS YS Lt' C'1 �10�..- 1,W�7lo.7L <br /> THIS FACILITY IS SUBJECT TO REINSPEqTIPN AT TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector: Recei y: Title: O �- <br /> EHD 23-04 <br /> Rev 06/22/07 <br />