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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.sil'ov.org,/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 4io <br /> loves 5 Iq awl <br /> Facility Address: Service Request#: <br /> �i •(mow ��' (,'ti�� S(2 � D S�Z �i <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manuf cturer Training: <br /> av Z�a I /,1.-� it VPA q <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> F-1 ❑ mechanical Model: El 1 hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: <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 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 /> Im <br /> ensor 222 Primary piping testing at: <br /> [,,positive shutdown Model: '/ ❑ psi <br /> 9fail safe Serial #:,-935 31?-2 <br /> NA minutes <br /> sensor <br /> ❑ <br /> El positive shutdown Model: ElSecond Secondary piping testing at: <br /> El 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 /> Ewverfill <br /> Drop tube with mechanical overfill at 95% ElCorrosion protection <br /> prevention (see LG letter 150-1) ❑ Other: see below <br /> 1 � ti w <br /> THI§ FA ILITY IS SUBJECT TO REINSPECTION AT ANYTIME AT EHD'S CURRENT HOURLY RATE. <br /> EH ect Recei dB Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />