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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.sjjzov.org/eh <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: _ Inspection Date: <br /> AT 4- J �?f l 2/0 c( <br /> Facility Address: Service Request#: <br /> Zq- G." S/2U 0 56 Z 2 l <br /> Onsite Service Technician's Name: ICC Service Technician/installer Certification#: Manufacturer Training: <br /> 5 S2 l (o — C Z <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial : ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 El❑ electronic Serial #: ❑ 1 hour hydrostatic 11 Incon TS-STS <br /> El 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 El positive shutdown Model: ElPrimary piping testing at: <br /> si <br /> ❑ fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor <br /> Second <br /> ❑ El positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial#: p <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: UDC(s) (/t&,,� Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> 01 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 /> v�a� 1 •-S� PISl. <br /> w <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY <br /> /RATE. <br /> EHD Inspector: R i By: <br /> A� <br /> EHD 23-04 <br /> Rev 06/22/07 <br />