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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.sjgoy.or <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: 1 Inspection Date: <br /> 9 <br /> A' 6 -9-7 D0��W <br /> Facility Addr ss: Service Request#: <br /> Fn*wd-R. %,Ac4zp�f "' I Q r- <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket minimum 5 gallon <br /> El <br /> El electronic Serial #: 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ 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 /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> 1:1 electronic Serial ❑ El hour hydrostatic El Incon TS-STS <br /> El line test programmed El Caldwell System ❑ Other <br /> sensor <br /> ❑ <br /> El shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fall 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 /> EDrop tube with mechanical overfill at 95% ElCorrosion protection <br /> ll prevention (see LG letter 150-1) ❑ Other: see below <br /> ` <br /> q( `I <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inso Rec ' By Titles <br /> p9e t <br /> L� <br /> EHD 23-04 <br /> Rev 06/22/07 <br />