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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 304 East Weber Avenue,P 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 Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> �670 Vh T� f 1 <br /> Onsite Service Technician's Name: ICC Service Tech nician/Installer Certification#: Manufacturer Traini (0 18.[}:I <br /> SERVICE SERVICE <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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> El ' ❑ 111 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor TUYhInL <br /> shutdown Model: �'3�0` 73 Primary piping testing at: <br /> Wtositive <br /> ail safe Serial#: 2,653 Q psi <br /> El minutes <br /> ❑ NADK <br /> sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> El ❑ psi <br /> ❑ fail safe Serial#: <br /> minutes <br /> ❑ NA <br /> sensor <br /> El ❑ positive shutdown Model: El Secondary containment repairs for: Piping <br /> El fail safe Serial#: O <br /> Sump(s) UST(s) <br /> El 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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> D Inspe or gReceve,iBy: z� Ti,EHD 23-04 <br /> 1/3/07 <br />