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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:wwwJgov.o <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fa ci'ty Name: Inspection Date: <br /> w: <br /> /a . Zd o <br /> Faci tty Address: Service Request#: <br /> I/ <br /> O 'te Service Technician's Name: IC ervi a Techni 'an/ nstaller Cert' ation#: Manufacturer Training: <br /> vii 5 2 a . 2 Ll� — <br /> [ l <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 <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed El 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 /> El fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor <br /> El El positive shutdown Model: Secon psi piping testing at: S ? <br /> El fail safe Serial #: 11— D <br /> 0 minutes <br /> El NA <br /> sensor Secondary containment r pairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> El fail safe Serial #: ( ) p g <br /> El NA Sump(s) UST(s) <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 /> a0 I* , or OWE g>7 <br /> 144 OP �71M <br /> THIS ACILIT IS SUBJECT TO REINSPECTION T ANYTIME AT EHD'S URRENT HOURLY RATE. <br /> E sp or eceiv By: Title: <br /> EHD 23-04 <br /> Ray 06/)'?/n7 <br />