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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME(N f <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.ss gov_orehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facili Name: Inspection Date: <br /> " + VY 0,- OK <br /> Facility Add r ss: Service Rest#: <br /> 3toE 'SM72dW06-*�- <br /> O he Service Tech 'clan's e: ICC Ser i¢e Technician/Installer Certification#: Manufacturer Training: <br /> Na� 5��� � <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 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 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 /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> El 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 /> E <br /> Drop tube with mechanical overfill at 95% L1Corrosion protection <br /> ll prevention (see LG letter 150-1) ❑ Other: see below <br /> ALTHIS FACILITY IS SUBJECT TO REINSPECTION AT D'S CURRENT HOURLY RATE. <br /> ED Gas ct Received By: Titl <br /> N �(<0 A <br /> J <br /> EHD 23-04 <br /> Rev 06/22/07 <br />