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SAN JOAQUIN COUNTY <br /> 0 ENVIRONMENTAL HEALTH DEPARTMEN <br /> 304 East Weber Avenue,Yd Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility �-70� <br /> Date:S ),& <br /> I <br /> Facility Address: Service Ifequest#: <br /> � W, L ov� 01570.7 5P,71 00 s-10 I z <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> �u Z*ntV-\ 524 2 4{I - t T 4?1 g(61 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed 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 ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> amEl Caldwell System ❑ Other <br /> El line test ro rmed <br /> sensor <br /> F1 El shutdown Model: El psi piping testing at: <br /> ❑ fail safe Serial#: p <br /> minutes <br /> ❑ NA <br /> sensor <br /> El El shutdown Model: El psi piping testing at: <br /> 11 fail safe Serial #: p <br /> minutes <br /> ❑ 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 /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> 6f 1 6�I I ftAq4q- iS5 lweg 4nL dr 1 hk, <br /> THIS FA ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> T1 o ec Received Title: <br /> _ EHD 23-04 <br /> 1/3/07 <br />