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r <br /> r <br /> - SAN JOAQUIN COUNTY 1P <br /> ENVIRONMENTAL 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 /> P-C-(;) 2133 9 z 1a� <br /> Facility <br /> Address: Services egquuest#: <br /> Onsite ervice Technician's Name: ICC Service Technician/installer Certification#: Manufacturer Training: 1p <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El El❑ electronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial ❑ ❑ 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> El 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 /> ensor `►i 115u--P <br /> positive shutdown Model: VR- 3�3 Primary piping testing at: <br /> El psi <br /> fail safe Serial#: -7,? -3Sa 323 <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <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 /> D <br /> THIWCILIT,Yt,IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect Received By: Title: <br /> 0 <br /> EHD 23-04 <br /> Rev 06/22/07 <br />