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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.sieov.orjz/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: C,� <br /> / Inspection Datq� o In ?-4, 0o45 Co q r< < ZO 0 <br /> Facility Address: Service Request#: <br /> 1 g 1 O -1-(CL Z��-�-o� S l- 0 0 8 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> $o 14 62�'L) V -Z34-6 6 q <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 <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> F1 ❑ electronic Serial#: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> E] Caldwell System E] Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: 13 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro ammed El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial#: <br /> minutes <br /> F-1 NA <br /> sensor <br /> ❑ El positive shutdown Model: ❑ Secondary piping testing at: <br /> F] fail safe Serial #: p <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Pi <br /> ❑ fail safe Serial#: ( ) pin g <br /> 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 /> i I►-QSV Z s-r0.r r' i fNO C <br /> ko 4o VP, TLS 35o i2rLAP-1.1 �✓p C -� <br /> r h+Sfbr' ri In o �t <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec or: Received By: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />