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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/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> ,91*fN c- -§7?96&,7Dn/ 1// Zl d 9 <br /> Facility Address: Service Request#: <br /> 1 l v (,Da(-APzd ! Ka 0 S"o O <br /> Onsite Service Technician's Name: ICC Service Technician/installer Certification • Manufacturer Training: <br /> C l y Mocaawo lar 2 715>0- L,(Tlh/d F, <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: b:M--Spill bucket 51minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ;K 021 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: El 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System 11 Other <br /> El line test ro ammed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 1:1 Caldwell System ❑ Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> F-1 Elfail safe Serial #: ❑ psi <br /> minutes <br /> ❑ NA <br /> sensor <br /> ❑ s) in <br /> ❑ positive shutdown Model: ❑ Secondary containment( repairs for: Pi <br /> El fail safe Serial #: UDC(s) g <br /> ❑ 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 /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: 1 -7 'eceved By: <br /> � Title: <br /> EHD 23-04 <br /> Pav nn/99/n7 <br />