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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/ehd <br /> UNDERGROUND STORAGE TANK ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: service Request#: <br /> Onsite Technician's Name: ICC SindaTBchnieian/lastaller Certification#: Manufacturer Training: <br /> IZ <br /> �otrc� hoorL Z2} 04 Fi'z,," E4-4:L4es { <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 <br /> ❑ Elpositive shutdown Model: ElPrima ppiping testing at: <br /> 11 fail safe Serial#: p <br /> minutes <br /> 11 NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ si <br /> ❑ fail safe Serial #: p <br /> minutes <br /> 11 NA <br /> sensor Sec n�d/i/9 UDC(s) <br /> repairs for: <br /> ❑ El positive shutdown Model: to IS UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> 01 Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ 1 Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> LA s /o S or— <br /> THIS <br /> FACILITY IS SUBJECT TO REINSPE9TI0,N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp RCCfI By: Title: <br /> EHD 23-04 <br /> Rev 06122/07 <br />