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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.sjgov.orgkehd <br /> UNDERGROUND STORAGE TANK LUST) P GRAM SERVICE REQUEST INSPECTION "PORT <br /> Facility Name: Inspection Dat <br /> 1 1 AYVI,— 4:7 <br /> Facility Address: Service equest 0 <br /> 7-701 Syk Oos- <br /> Onsite Service Technician's Name: ICC service Technician/Installer Certification#: Manufacturer Training: <br /> V x,itGoo? <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System R Other <br /> F ❑ <br /> El line test programmed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ El mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial El Caldwell System El Other <br /> 0 line test programmed <br /> . Leak detector Spill bucket El minimum 5 gallon <br /> D mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial #: R Caldwell System 0 Other <br /> 0 line test rogrammed I - <br /> sensor Primary piping testing at: <br /> ❑ 0 positive shutdown Model: psi <br /> 0 fail safe Serial#: minutes <br /> 0 NA <br /> sensor Secondary piping testing at: <br /> R positive shutdown Model: ❑ Psi <br /> El fail safe Serial #: minutes <br /> ONA <br /> sensor Secondary containment repairs for: <br /> ❑ 0 positive shutdown Model: ❑ UDC(s) Piping <br /> 0 fail safe Serial #: sump(s) UST(s) <br /> 0 NA <br /> ❑ Drop tube with mechanical overfill at 95% Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% 0 Corrosion protection <br /> 1 <br /> R Overfill prevention(see LG letter 150-1) 0 Other: see below <br /> V 0.4�6jhr <br /> THIS FAC <br /> PTY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDIS CURRENT HOURLY RATE. <br /> EHD lisp r: ed B Title: <br /> v By: e�- �� I <br /> 1 --7-- V <br /> EHD 23-04 <br /> c+,.—r(-f"fr)7 <br />