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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 Far.(209)468-3433 Web: www.sijzov.orjz/eh <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility ame: Inspectionate: <br /> Facility Address: Service Request#: <br /> 3zi v. 9/_1:;Z0C:1S <br /> Onsite Service Technician's Name: 1 Service Technician/installer Certification#: Manufacturer Training: <br /> yu <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> F-1 ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: El Caldwell System El Other <br /> El line test programmed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ Elmechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: El Caldwell System F-1 Other <br /> ❑ line test programmed <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 <br /> El shutdown Model: Primary piping testing at: <br /> El <br /> 1-1failsafe Serial #: ❑ psi <br /> minutes <br /> El NA <br /> sensor <br /> ❑ Second❑ positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor <br /> Secondary containment repairs for: <br /> F-1El positive shutdown Model: <br /> F-1 fail safe Serial #: El UDC(s) Piping <br /> ❑ 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 /> CK a�t� l <br /> ;r.s <br /> THIS FACILITY IS SUBJECT TO REINSPECTIONAT ANY ThME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins tor: eived B Title <br /> EHD 23-04 <br /> Rev 06/22/0 <br />