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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:www.sigov.org/chd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> `5 1 v <br /> Fa dity A ess: I Service Uequest#: <br /> r 6a Aum 59003'4q3 <br /> Onsite Service Technician's ame: ICC Service Technician/installer Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial 11 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El 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 /> D'rsa..l n,, ensor VA-7q zf390—qb-7 <br /> ,E] positive shutdown Model: ✓g 4o� Primary piping testing at: <br /> ❑ psi <br /> fail safe Serial #: 69DZ35' minutes <br /> ❑ NA <br /> sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> ❑ <br /> El fail safe Serial #: Elpsi <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 /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) Lw❑ Other: see below <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHDInsp o Rec ed By: Title: <br /> A( A4.40P — lve-,-,A—;;;' <br /> EHD 23-04 <br /> Rev 06/22/07 <br />