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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.sjg_ov.or /P ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Na Inspection Date: <br /> 1'- ;D:1 Li I - Lf 015 <br /> Facility Address: Service Request#: <br /> 12 .5 • 00 ss 131 <br /> Onsite Service Tech ician's Name: ICC Service Technician/installer Certification#: Ma fturer raining::s J'V: V <br /> tV'j <br /> SERVICE SERVIC <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ El electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System El Other <br /> El line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑ fail safe Serial #: p <br /> minutes <br /> 11 NA <br /> sensor <br /> Second <br /> ❑ ❑ positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <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 04 ,, WAW <br /> Q 4 b i 4rates compteke, <br /> C.&Z <br /> THM FACILITY IS B C TO) EIN PEC ION AT ANY I EHD'S CURRE HOURLY RATE. <br /> EHD Ins Rec 'ved By: Title: <br /> EHD 23-04 <br />