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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTM EN, <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.9goy or ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fafility Name: n Inspection Date: <br /> Facility A;ress* Service Request#: <br /> . W, s12 0 <br /> ite Service Technic n's Name: ICC Service Technician/Installer Certification#: NUnufacturer Training: <br /> rM*6w <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 El hour hydrostatic El Incon TS-STS <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El electronic Serial El El hour hydrostatic El Incon TS-STS <br /> El Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> El shutdown Model: Primes piping testing at: <br /> El �2� Psi <br /> El fail safe Serial #: � <br /> 50 _minutes <br /> El NA <br /> sensor edary piping testing at: <br /> El El positive shutdown Model: ❑ consi <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ 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 /> 2�F 0A a U Vl OC -32iN `►u <br /> 0 �f4cw S ; �t,, �o ,t-I,; s <br /> N s <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> H In pec Receiv y: Title: <br /> D 23-04 <br /> Rev 06/22/07 <br />