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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fac:(209)468-3433 Web: www.sigov.org/ehd UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspection Date: S� It-7- ag Facility Address: f Service Request#: (-,,4-Z S �-Cre- 52 528 (QC) Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: SERVICE SERVICE Leak detector Spill bucket ❑ minimum 5 gallon ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS ❑ electronic Serial #: ❑ Caldwell System ❑ Other ❑ line test programmed Leak detector Spill bucket ❑ minimum 5 gallon ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS ❑ electronic Serial #: ❑ Caldwell System ❑ Other ❑ line test programmed Leak detector Spill bucket ❑ minimum 5 gallon ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS ❑ electronic Serial #: ❑ Caldwell System ❑ Other ❑ line test programmed sensor Primary piping testing at: ❑ ❑ positive shutdown Model: ❑ psi 11 fail safe Serial #: minutes ❑ NA sensor Secondary piping testing at: C,5-/9 ❑ ❑ positive shutdown Model: psi ❑ fail safe Serial #: E] NA minutes sensor Secondary containment repairs for: ❑ positive shutdown Model: ❑ ❑ fail safe Serial #: IT} Z U Piping El NA Sumrnpp(ss) UST(s) ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection ❑ Overfill prevention (see LG letter 150-1) ❑ n Other: see below $� h-C4 �rc.� eC L 5i Fi�— r. no 14 G u4-5 sss i THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. EHD Inspector: Received By: Title: C✓L/ �T� EHD 23-04 Rev 06/22/07