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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME. <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.or ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Faci'ty N me: jh4m <br /> Inspection Date: C <br /> v <br /> F7** Address: RK ce Ret <br /> Onsite Service echnician's Name: ICC�Service Technician/Installer Certification#: fflanufacturer Trr��''���I in <br /> rl <br /> ERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon - <br /> ❑ ❑ electronic Serial El 1 hour hydrostatic El Incon TS-STS <br /> El Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial 11El1 hour hydrostatic [I Incon TS-STS <br /> El line test pro ammed El Caldwell System ❑ Other <br /> Leak detector <br /> F-1 mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial ❑ El hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> 1:1 fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> 11 fail safe Serial #: ( ) p g <br /> El 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 /> TH F I ITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> t eived Title:IT <br /> EHD 23-04 <br /> Rev 06/22/07 <br />