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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTM* <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sj2ov._org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> T <br /> ility Name: l� Inspection Date: <br /> "l � S , 16 , 6-7 <br /> Facilitydress: Service Request#: <br /> Io- W. 0 m 5T W�i G-t SAO()SI?-I 3 <br /> O <br /> Re Service echnician's Name: ICC Service Technician/Installer Certification#: Ma of turer Training: <br /> j"I J vowaw <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial : ❑ F-11 hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System El 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 /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line testro ammed <br /> V\ i ensor <br /> Primary piping testing at: <br /> 1❑ <br /> positive shutdown Model: C&/ ❑ psi <br /> ❑ fail safe Serial #: 2 <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ positive shutdown Model: 209 ❑ psi <br /> ❑ fail safe Serial minutes <br /> ❑ NA <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 /> &A <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT TIME AT EHD'S CURRENT HOURLY RATE. <br /> uw� &,ved y: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />