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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENO <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION "PORT <br /> Facility Name: Inspect.1 ate. <br /> F.ciliVyAddress:T Service 14equest#: <br /> Onsite Service Technician's Naml ICC Service Technician/Installer Certification Manufacturer Training: 7tz— <br /> 'fle — <br /> a* &"Vt: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ El mechanical Model: El El 1 hour hydrostatic El Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System 0 Other <br /> 0 line test 2roEammed <br /> Leak detector Spill bucket D minimum 5 gallon <br /> 0 mechanical Model: El [I I hour hydrostatic E3 Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System El Other <br /> El line test programmed <br /> . Leak detector Spill bucket El minimum 5 gallon <br /> ❑ 0 mechanical Model: ❑ <br /> 0 electronic Serial#: M I hour hydrostatic D Incon TS-STS <br /> D line test proEammed E3 Caldwell System ElOther <br /> du- Primap I if sensor piping testing at: <br /> posit e s OwAlmodel: El V T - si <br /> fail safe OrlSerial#: 217,519 minutes <br /> 0 NA <br /> sensor Secondary piping testing at: <br /> 0 positive shutdown Model: ❑ psi <br /> 0 fail safe Serial#: minutes <br /> 0 NA <br /> sensor Secondary containment repairs for: <br /> 0 positive shutdown Model: El Secondary <br /> Piping <br /> 0 fail safe Serial#: sump(s) UST(s) <br /> 11 NA <br /> ❑ Drop tube with mechanical overfill at 95% 0 Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% 0 Corrosion protection <br /> 11 Overfill prevention(see LG letter 150-1) 0 Other: see below <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDIS CURRENT HOURLY RATE. <br /> E Inspe or: ecetvBy- Title: <br /> -J LA <br /> EHD 23-04 <br /> 1/3/07 <br />