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SAN JOAQUIN COUNTY We <br /> cNVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 5KYMA-R'---1 EN�t Pf►S-S C)14r. cAre) NO Z409 <br /> Facility Address: Service Request#: <br /> q1:3 u. 1!!�/_ DOP14DO %C00-5S32.6 <br /> Onsite Service Technician's Name: ICC Servi a Technician/installer Certification#: I Manufacturer Training: P <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑Fiechanical 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 ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial E3 1 hour hydrostatic ❑ Incon TS-STS <br /> El Caldwell System ❑ Other <br /> El 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 /> ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ fail safe Serial #: ❑ psi <br /> minutes <br /> ❑ NA <br /> sensor <br /> El positive shutdown Model: Secondary piping testing at: <br /> El Elfail safe Serial #: ❑ psi <br /> minutes <br /> [INA <br /> sensor <br /> ❑ positive shutdown Model: Secondary containment repairs for: <br /> ❑ ❑ fail safe Serial #: E] UDC(s) Piping <br /> ❑ NA Sump(s) UST(s) <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) ❑ Other: see below <br /> C r s <br /> C1�• <br /> Lt 00 A s ywlm <br /> THIS FACILITY IS SUBJECT TO REINSPECTION IME AT EHD'S CURRENT HOURLY RATE. <br /> Inspector: /I l�/ Receiv ,� - _ Title: <br /> V /, J ll l/ <br /> EHD 23-04 <br /> Rev 06/22/07 <br />