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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.sigoy.orz/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility N me. Inspection Date: <br /> L <br /> Facility Address: Service Request#: <br /> �j I �6j� ' �� \iQ - �'r -q M sl <br /> On Re Service Technician's arae: ICC Service Technician/I staller Certification#: Manufacturer Training: <br /> b►v�v �-13-`jolU 3 -�-�rso ��S' G-1�-0�' <br /> SERVICE SERVICE <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 /> 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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> 13 ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#:❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: p <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> 11 fail safe Serial#: <br /> ❑ NA minutes <br /> sensor Secondary containment repairs for: <br /> ❑ positive shutdown Model: ( ) Piping <br /> 13 ❑❑ 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 /> El Overfill prevention(see LG.letter 150-1) Other: see below <br /> &S" ow� MM aw `1Nbk SON W yet\+ j;tg-A(fe6ak4wL <br /> � J <br /> unrU Co , er1 <br /> tO A I,A1-I&9�, h--1) <br /> ion) ' AV <br /> THIS FACILITY IS SUBJECT TO REI NSPECTIO AT ANY TIME AT EH 'S CURRENT HOURLY RATE. <br /> EHD fnsCReceived By Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />