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iSAN 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.orj4/e <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> i a Ue <br /> Facility Address: Service'Request#: <br /> //iZO -2-7zA w 'ff�f--JnO s///-2— <br /> Onsite <br /> nsite Service Technician's Name: ICC Service Technician/installer Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> 11 electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro ammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> 1:1 line test programmed <br /> ❑ 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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> 13 fail safe Serial #: <br /> ❑ NA minutes <br /> sensor <br /> El positive shutdown Model: Secondary piping testing at: <br /> ❑ E] psi <br /> ❑ fail safe Serial#: <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial#: <br /> Sum s UST(s) <br /> El NA <br /> Sump(s) <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 /> ® 1I ��f D <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIMt AT EtIDIS CURRENT HOURLY RATE. <br /> EHD Inspector Rec v B Title; -7�„ <br /> EHD 23-04 <br /> Rev 06/22/07 <br />