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SAN JOAQUIN COUNTY <br /> is ENVIRONMENTAL HEALTH DEPARTMEIFT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.sjgov.orgLehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION "PORT <br /> Facility Name: Inspection Date. <br /> W I S%Vl Wgi ONVV owl $11)10-7 <br /> Facility Address:I Service eq est#: <br /> q11 V, W-Aw Oki ";IU15109 <br /> Onsite Service Technician's Namd- ICC Service Technician/Installer Certification 4anin <br /> cu <br /> ufa lTX <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El El mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial #: 0 Caldwell System 0 Other <br /> 0 line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El El mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: El Caldwell System 0 Other <br /> 0 line test programmed <br /> . Leak detector Spill bucket 0 minimum 5 gallon <br /> 0 El mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System El Other <br /> 0 line test 2rogrammed <br /> r <br /> int sensorkotv%q -4 Primary piping testing at: <br /> 0tive shutdown Model: Elpsi <br /> safe Serial#: <br /> 0 NA minutes <br /> sensor Secondary piping testing at: <br /> 0 0 positive shutdown Model: 0 psi <br /> 0 fail safe Serial#: <br /> El NA minutes <br /> sensor Secondary containment repairs for: <br /> 0 El positive shutdown Model: UDC(s) Piping <br /> 0 fail safe Serial#: Sump(s) UST(s) <br /> DNA <br /> ❑ Drop tube with mechanical overfill at 95% F-1 Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% 0 Corrosion protection <br /> El Overfill prevention(see LG letter 150-1) E] Other: see below <br /> THIS FACILITY IS SUBJECT TO REINSPEqIIQMkT ANY TIME AT E 'S CURRENT HOURLY RATE. <br /> '5JI'Ved B;��-' Title: <br /> D Inspector: <br /> ImIfOLIA11 <br /> EHD 23-04 <br /> Rev 06/22/07 <br />