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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.org/e <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: n_ Inspection Date: <br /> Facility Address: Service Request#: <br /> 124 w L-c.M 4 .i t�0� I 59O()-967Z Z 1 <br /> Onsite Service Technician's Name: I&Service Technician/Installer Certification#: Manufacturer Training: <br /> 152—G2-407— U1 ✓E FIS Rl t,t6uN� c c—IST <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: ❑ 111 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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> E] fail safe Serial #: <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: psi <br /> ❑ fail safe Serial #: <br /> El NA —rszCL minutes <br /> sensor Secondary containment repairs for: <br /> ❑ <br /> El positive shutdown Model: UDC(s) UGTr Piping <br /> ❑ fail safe Serial #: <br /> 11 NA sump(s) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> O Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> L 4evqx vvw s g , vka, 4Lk <br /> �cdi t�vt�o- d�s� 42cue <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rec i X <br /> 1 Title: <br /> ie4e e��rul� <br /> EHD 23-04 <br /> Rev 06/22/07 <br />