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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.s'gov.org/ <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: C Inspection Date: <br /> Facility Address: Service Req est#: <br /> Lf-OLf 0 (,j&0-/- 4s cam— �vR 528r�8' <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> ST' S7,5'236-7–u T' <br /> r ---6-51d llw5;7-5 211W7 <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 Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: El El1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System ElOther <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ si <br /> ❑ fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: El — si <br /> ❑ fail safe Serial #: p <br /> 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 /> LEEI <br /> Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> Drop tube with mechanical overfill at 95% ElCorrosion protection <br /> Overfill prevention(see LG letter 150-1) Other: see below ((j�c / ; <br /> S SO <br /> / <br /> �+ t....¢ R ,L l I"e– a <br /> PV; f:' ��.s� FGSfe.s <br /> ve,— -IA.- <br /> THIS FACILITY IS SUBJECT TO REIN PECTION AT ANY To& AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect '7L— Receiv y: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />