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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.sjQov.orWehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility arae: 1 Inspection Date: <br /> �-45 1 � � l,l (- �� <br /> Facility Address: C'� Service Request <br /> 1225 VJ . ��- <br /> Onsit Service Technician's Name: ICC Service Technician/installer Certification#: Manufacturer Training: <br /> to -3 FCS3- <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket F-1 minimum 5 gallon <br /> El ❑ electronic Serial El 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> 1:1 Caldwell System El Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial : El El hour hydrostatic ElIncon TS-STS <br /> F-1 Caldwell System ❑ Other <br /> El 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 /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> psi <br /> ❑ fail safe Serial#: ❑ minutes <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor <br /> ❑ positive shutdown Model: Secondary containment repairs for: <br /> El ❑ fail safe Serial #: El UDC(s) Piping <br /> Sump(s) UST(s) <br /> El NA <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% EDCorrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) Other: see below <br /> t xeA gdw IlNegt <br /> 1.1"A d '1Ikm,k&i An c,-,hKl 4 ckjjm�&,M lr� 4e, PW(A1,A AeA 01A� -'Will <br /> 6 1 VST <br /> THIS FACILITY IS SUBJECT TO REINSPECT105 AT ANY TIME Aj EHD'S CURRENT HOURLY RATE. <br /> EHD[nsp to: Receiv Title• <br /> ` �� <br /> EHD 23-04 <br /> Ra,.nai99im <br />