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SAN JOAQUIN COUNTY <br /> qNVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org;ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE RE2UEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> 16 1 Cl bo �� �� ��-. <br /> Onsite Service Technician's Name: [CC Service Technician/installer Cdtification#: anufa h er Tr 'Hing <br /> ��t�.. .�-76-7���3-76 <br /> 15111534 <br /> SERVICE SERVICE <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-rogrammed <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ® ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic 1:1 Incon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> ❑ line testroammed <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 proEammed <br /> sensor <br /> D ❑ positive shutdown Model: ® Primary piping testing at: <br /> si <br /> El fail safe Serial#: p <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: L <br /> si <br /> ❑ fail safe Serial#: p <br /> ❑ NA minutes <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% ( l Cold start of monitoring panel <br /> ffiWverfill <br /> Drop tube with mechanical overfill at 95% ❑ Corrosion protection prevention(see LG letter 150-1) ❑ Other: see below <br /> r - <br /> a <br /> THIS FA61LITY IS SUBJE&TO REINRECtIOAAT ANY TIME AT EH 'S CU ENT HO RLY RATE. <br /> EHD Inspecto• R eiv Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />