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0 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.sijzov.org/eh <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> vio l (o -312-3;L <br /> Facility Address: Servi a Request#: <br /> 2,701 kJ 5/2 obs v <br /> Onsite Service Technician's Name: ICC Service Technician/installer Certification#: Manufacturer Training: <br /> tib - MZ-Lz> r � <br /> rr 11aa,� 1 ihn <br /> SERVICE SERVICE <br /> Leak detector Spill bucket Elminimum 5 gallon <br /> mechanical Model:� t I 1 hour hydrostatic ❑ Incon TS-STS <br /> 1:1electronic Serial #: � 16 — �S/, ❑ Cald el Sys ❑ her <br /> ❑ line test programmed o qo`] q®� <br /> �L Leak detector <br /> �- Spill bucket El minimum 5 gallon <br /> 'Ekmechanical Model: <br /> 11 electronic Serial #: El 1 hour hydrostatic ❑ Incon TS-STS <br /> j(6 —o�E� El Caldwell System ❑ Other <br /> ❑ line test programmed 1 p o 0 <br /> ' /Leak detector <br /> .,mechanical Model: � Spill bucket ❑ minimum 5 gallon <br /> ❑ electronic Serial #: — S ❑ El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed l $ ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ ❑ fail safe Serial #: ❑ psi <br /> El NA minutes <br /> sensor <br /> El positive shutdown Model: Secondary piping testing at: <br /> El Elfail safe Serial #: ❑ psi <br /> 1:1 NA minutes <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 dl' fze- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Recey: Title; <br /> l o��- <br /> EHD 23-04 <br /> Rev 06/22/07 <br />