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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> IP <br /> 304 East Weber Avenue,3`d Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 lax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 2 fD Ilc( --7 • 1B' 67 <br /> Facility Address: Service Request#: <br /> 2?,715 N •' 131gP 065-11 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> L uL <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: X <br /> Spill bucket minimum 5 gallon <br /> ❑ El electronic Serial#: X 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial El 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial : El 1 hour hydrostatic ElIncon TS-STS <br /> El Caldwell System ❑ Other <br /> El line test programmed <br /> sensor <br /> El El shutdown Model: El psi piping testing at: <br /> ❑ fail safe Serial #: p <br /> minutes <br /> ❑ NA <br /> sensor <br /> ❑ Second❑ positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> El 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 /> F <br /> Drop tube with mechanical overfill at 95% ElCorrosion protection <br /> ll prevention (see LG letter 150-1) ❑ Other: see below <br /> W <br /> G�I�I.rn iGl <br /> THIS FACILITY IS SUBJ CT TO REINSPEC ON AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> H ,Ins ect e' e Title: <br /> LP <br /> EHD 23-04 <br /> 1/3/07 00 <br /> 1.w" <br />