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%awl.. a <br /> 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.orWehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 6n G/ n f,,,/ Z._. Til U <br /> Facility Address. Servic eques[#: <br /> Onsite Service Technician's Name: ICC Service Technichu dinstaller Certification#: yrlanufacturer Training: <br /> i �/1/6r, Sou -�—c� Iz/s�L(;u . 1 rW/� �-ti•6� x� 1/�sr�° <br /> SERVICE SERVICE <br /> Leak detector �a-fvo U( f <br /> F Spill bucket El minimum 5 gallon <br /> mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> / ❑ electronic Serial #: r7-7, 116:3 ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector F6 ,v tit j,a <br /> M Lf) bucket ❑ minimum 5 gallon <br /> mechanical Model: Sr—P— <br /> ❑ electronic Serial #: o7 Ib if g-D ❑ 111 hourhydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> C6c,L,/ Leak detector FC 0Q¢,D (k (�s CvP <br /> mechanical Model: —MLS n Spill bucket El minimum 5 gallon <br /> I R ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 7U ❑ electronic Serial #: �wq f at ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> 1 ❑ ❑ positive shutdown Model: ❑ Primaryps piping testing at: <br /> ❑ fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor IN Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: p <br /> ❑ NA minutes <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 /> fc fU 1", <br /> r <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp�� /;e2 , Received ay: ,� —� Title: <br />