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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/e <br /> UNDERGROUND STORAGE TANK ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Pte# 0 -117-3 "�- 1� <br /> Facility Address: Servide Request#: <br /> 40 GJ,-- 1 & o {._ S QROC>5417Cs <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <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: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 11 electronic Serial #: <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <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#: <br /> minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> minutes <br /> El 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 /> El Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfilll prevention(see LG letter 150-1) Other: see below <br /> 1+ <br /> �� ��` '5 <br /> U M9177b— r h IS" Ao.— 6,1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHWS CURRENT HOURLY RATE. <br /> EHD Inspw[oc Received B : Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />