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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME� <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.si2ov.org/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Na a Inspection Date: <br /> Facility Address: Service Request#j <br /> A,3l N. W Ub 5 <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 /> 1:1 mechanical Model: <br /> E] ❑ electronic Serial #: � )01 hour hydrostatic El Incon TS-STS <br /> 1:1 line test programmed <br /> El Caldwell System El Other <br /> Leak detector <br /> Spill bucket ) minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ 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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial#: <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 /> EOverfill <br /> Drop tube with mechanical overfill at 95% ElCorrosion protection <br /> prevention(see LG letter 150-1) ❑ Other: see below <br /> a � — I -aSc�m - 12•r <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> MRived Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />