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0 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj og v.or <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate:� <br /> Seo 4 -76 t `�-� <br /> Facility Address: Service Request#: <br /> 036 S, S2004 18(-I2- <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> e r c- ti M 2 ov D low <br /> SERVICE 11 ; q $ �- SERVICE <br /> Leak detector �Spill bucket 1 minimum 5 gallon <br /> ❑ ❑ mechanical Model: �" ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial#: Caldwell System M Other <br /> ❑ line test programmed D g 1 -,,j <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor <br /> Second <br /> El positive shutdown Model: F-1psi <br /> piping testing at: <br /> 1:3 fail safe Serial #: p <br /> minutes <br /> E] NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: ( ) p g <br /> 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 /> w0 U1 a�-- <br /> ��� Pro vv <br /> u Z �t <br /> l vie, e <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD In ector: Recei Title: <br /> ---- <br /> V 1,for-j <br /> EHD 23-04 <br /> Rev 06/22/07 <br />