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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.or /P ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> _1 •G��o. Dg <br /> Facility Address: Service Request#: <br /> site e%e T chniciatn''s� ICC Se ce ecb�[nstaller Certification#: Mau cty;er TrT <br /> 5 � 7�— 1" <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: <br /> 11 electronic Serial 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro ammed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed El Caldwell System ❑ Other <br /> Leak detector Spill bucket Elminimum 5 gallon <br /> El ❑ mechanical Model: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ si <br /> ❑ fail safe Serial #: p <br /> 1:1 NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> ❑ NA minutes <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 <br /> l�1 1 Gt <br /> THIS FA LITY IS SUBJECT TO REINSPECTION A Y TIME AT EHD'S CURRENT HOURLY RATE. <br /> E s or: Received By: TitleGl � ��j <br /> s— --j <br /> trf �NrX� — <br /> EHD 23-04 <br /> Rev 06/22/07 <br />