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FF, MOI3 11:29 10/OS/200� FAX 33433 20916 Z001 SAN dOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Fc`lity Name: Inspeetisa Date: - l Facility Address: U Service Request #: 1gov w � l (0 ok 34 l Onsite Service Technician's Name:ICC Service TechnaMnstaller Certification #: Mawbctarcr Training: it �U✓ S qb q1 `o M10 �% ' 1��i SERVICE Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed Leak detector ❑ ❑ mechanical Model: ❑ electronic Serial #: ❑ line test programmed sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA sensor ❑ ❑ positive shutdown Model: ❑ fail safe Serial #: ❑ NA sensor Eli❑positive shutdown Model: ❑ fail safe Serial #: ❑ NA Drop tube with mechanical overfill at 95% Drop tube with mechanical overfill at 95% verfill -" IL - • � %-J 14ULLCr I DU -I) SERVICE Spill bucket ❑ ❑ 1 hour hydrostatic ❑ Caldwell System Spill bucket ❑ ❑ 1 hour hydrostatic ❑ Caldwell System Spill bucket ❑ ❑ 1 hour hydrostatic ❑ Caldwell System minimum 5 gallon Incon TS -STS = Other ❑ minimum.5 gallon ❑ Incon TS -STS ❑ Other ❑ minimum 5 gallon ❑ Incon TS -STS ❑ Other Primary piping testing at: ❑ psi minutes Secondary piping testing at: ❑ psi minutes Secondary containment repairs for: ❑ UDC(s) Piping Sumps) UST(S) Cold start ofmonitoring panel VN ❑ Corrosion protection FOOther: see below