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SAN JOAQUIN COUNTY <br /> 4DENVIRONMENTAL HEALTH DEPARTMENO <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.sigov.orgjehd <br /> UNDERGROUND STORAGE TANK(UST 2 PROGRAM SERVICE REQUEST INSPECTION "PORT <br /> Facility Name: Inspection Date <br /> k-) —,,L <br /> Facility Address: Service Request ff* <br /> ODS356 62 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> 14/A <br /> I <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> 0 0 mechanical Model: 0 El I hour hydrostatic El Incon TS-STS <br /> 0 electronic Serial #: .0 Caldwell System 0 Other <br /> 0 line test programmed <br /> Leak detector —Spill bucket 0 minimum 5 gallon <br /> ❑ 0 mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: El Caldwell System 0 Other <br /> El line test programmed <br /> . Leak detector Spill bucket El minimum 5 gallon <br /> ❑ 0 mechanical Model: 0 0 1 hour hydrostatic El Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System F� Other <br /> 0 line test programmed <br /> sensor Primary piping testing at: <br /> ❑ 0 positive shutdown Model: ❑ psi <br /> 0 fail safe Serial #: <br /> 0 NA minutes <br /> sensor Secondary piping testing at: <br /> 0 positive shutdown Model: ❑ psi <br /> 0 fail safe Serial#: <br /> 0 NA minutes <br /> sensor Secondary containment repairs for: <br /> D positive shutdown Model: El UDC(s) Piping <br /> 0 fail safe Serial #: Sump(s) UST(s) <br /> E] NA <br /> F-1 Drop tube with mechanical overfill at 95% 0 Cold start of monitoring panel <br /> Drop tube with mechanical overfill at 95% 0 Corrosion protection <br /> E Everfill prevention(see LG letter 150-1) Other: see below <br /> V <br /> �2 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDIS CURRENT HOURLY RATE. <br /> EHD lnsvectoz;•�-� , ed By: Title: <br /> CA, <br /> EHD 23-04 <br /> Rev 06/22/07 <br />