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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-.5iggv.o_rg/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> jV�' q- ,o <br /> Facilit Add—: Service Request#: <br /> I.% coo�n 1�"PaN Gw S V- 55 <br /> Onsite Service Technician's Nam -. ICC Service Technician/installer Certification#: Manufacturer Training: <br /> ( umS 5242-3--76 - CO- ISI <br /> SERVICE SERVICE <br /> Leak detector µ <br /> Spill bucket ❑ minimum 5 gallon <br /> �[mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: 0(o I al ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector PC Pia Spill bucket ❑ minimum 5 gallon <br /> 9 mechanical Model: 97 —Irl0 , ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: 010 5[51S ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector :Fe F&W-D Spill bucket ❑ minimum 5 gallon <br /> rmechanical Model: �V• M V a ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> o electronic Serial #: 1)'1 p S I S{o J�' ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> El shutdown Model: ❑ Primary piping testing at: <br /> ❑ <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor <br /> Second <br /> El F-1positiveshutdown Model: El psi piping testing at: <br /> 11 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 /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> EJOverfill <br /> Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> prevention(see LG letter 150-1) 1 ❑ Other: see below <br /> $1 eat- :57,a <br /> ZZ Vl % O <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY IME AT EHD'S CURRENT HOURLY RATE. <br /> ins ec ived B Title: <br /> 1t MAO <br /> EHD 23-04 <br /> Rev 06/22/07 <br />