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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.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> lv)4,ed— L <br /> 5 <br /> FAcility Address: Servile Request#: <br /> Z-701 ///-2— <br /> ( I <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification Manufacturer Training: <br /> --F-"A3129 i <br /> SERVICE SERVICE <br /> Leak detector —Spill bucket El minimum 5 gallon <br /> 0 El mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial#: E-1 Caldwell System ❑0 Other <br /> 0 line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> 0 0 mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial R Caldwell System 0 Other <br /> 0 line test programmed <br /> I Leak detector Spill bucket El minimum 5 gallon <br /> 0 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial #: El Caldwell System El Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> El 0 positive shutdown Model: 0 psi <br /> F1 fail safe Serial#: minutes <br /> 0 NA <br /> sensor Secondary piping testing at: <br /> ❑ 0 positive shutdown Model: ❑ psi <br /> El fail safe Serial #: minutes <br /> 0 NA <br /> sensor Secondary containment repairs for: <br /> F1 0 positive shutdown Model: ❑ UDC(s) Piping <br /> El fail safe Serial sump(s) UST(s) <br /> 0 NA <br /> 0 Drop tube with mechanical overfill at 95% Cold start of monitoring panel <br /> 0 Drop tube with mechanical overfill at 95% 0 Corrosion protection <br /> 0 Overfill prevention(see LG letter 150-1) 0 Other: see below <br /> F <br /> A Ll 4-624=- 90 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec Recei ed Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />