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0 SAN JOAQUIN COUNTY is <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.st>;ov.org/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> G i r&(e--, V— -76 # 9-7D ,° q q C <br /> Facility Address: Service Request#: <br /> MO W . GCS /�(vd S�� SCoor .3�>1& <br /> Onsite Service Technician's Name: ICC Service Technician/installer Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El ❑ mechanical Model: ❑ El hour hydrostatic ❑ Incon TS-STS <br /> 11 electronic Serial #: <br /> El line test programmed <br /> ❑ 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 test programmed <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> F-1 <br /> 11 fail safe Serial #: El psi <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> El positive shutdown Model: <br /> El ❑ fail safe Serial #: ❑ psi <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ positive shutdown Model: UDC( ) 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 /> ❑ 1 Overfill prevention(see LG letter 150-1) X Other: see below <br /> fe-MI svbm i UP - )\)D �S <br /> n F� AJo f� t <br /> w e ev j tel, G d v j, - w,Oej Ins 4 /cel r ; <br /> THIS FACILITY IS SOBJECT TO REINSPECTION AT ANY TIME AT HD'S CURRENT HOURLY RATE. <br /> EA Inspector: Received By: Title: <br /> 7-4A1 C ©K/ ) 6'1 <br /> EHD 23-04 <br /> Rev 06/22/07 <br />