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SAN JOAQUIN COUNTY <br /> 'sENVIRONMENTALHEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sieov-017 hd <br /> UNDERGROUND STORAGE TANK ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: C? <br /> lc�C-f l✓as L ! -1 /0-7 f <br /> Facility Address: Servic equest#: <br /> Sfz Cis <br /> onsite/Service Technician's Name: ICC Service Technician/Installer C rti catiop#: anufacturer Training: <br /> /Ulh ►�/� / J�t'r�/i�`-rce IZtS bi. �. �v �(M �-y�i X- <br /> Z3 71 <br /> SERVICE SERVICE <br /> Leak detector F6 itL f Spill bucket ❑ minimum 5 gallon <br /> mechanical Model: y"I�-r^L-D ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: o7101 3 ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Fw ? O1 <br /> TP- MLD Spill bucket ❑ minimum 5 gallon <br /> mechanical Model: S ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: t771C� 11 SD ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector K6_{.d 4 is Spill bucket ❑ minimum 5 gallon <br /> mechanical Model: 5re-MLn---Z> ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: x-707 l W) 7 ❑ 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 /> ❑ ff 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 /> r� sc <br /> 41-- SW 150 <br /> t � Ic to i <br /> 0 -F- H <br /> 5 <br /> `7r-S� or, a fa� Ari <br /> '-Cts �'4/< /5 455�.aR T�� le `l' <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp R ed By: Title: <br /> EHD 23-04 <br /> Rev 06/22107 <br />