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SAN JOAQUIN COUNTY <br /> 'OENVIRONMENTAL HEALTH DEPARTMENTO <br /> 304 East Weber Avenue,3`d 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 REPORT <br /> Facility Name: Inspection Date: <br /> Z, <br /> Facility Address: Service Request#: <br /> ? <br /> A <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> [3/mechanical Model: Spill bucket 0 minimum 5 gallon <br /> 01' El 0 1 hour hydrostatic El Incon TS-STS <br /> 0 electronic Serial#: 1 —7 0 Caldwell System 0 Other <br /> 0 line test programmed <br /> Leak detector Spill bucket n minimum 5 gallon <br /> 0 D mechanical Model: n .0 1 hour hydrostatic 0 Incon TS-STS <br /> 11 electronic Serial 0 Caldwell System 0 Other <br /> 0 line test programmed <br /> . Leak detector Spill bucket 0 minimum 5 gallon <br /> 0 0 mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial#: 0 Caldwell System 0 Other <br /> 0 line test programmed <br /> sensor Primary piping testing at: <br /> 1:1 0 positive shutdown Model: El psi <br /> n fail safe Serial#: minutes <br /> 0 NA <br /> sensor Secondary piping testing at: <br /> 0 0 positive shutdown Model: ❑ psi <br /> 0 fail safe Serial#: minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> 0 [1 positive shutdown Model: UDC(s) Piping <br /> El fail safe Serial Sumps) UST(s) <br /> DNA <br /> 0 Drop tube with mechanical overfill at 95% n Cold start of monitoring panel <br /> 13 Drop tube with mechanical overfill at 95% 0 Corrosion protection <br /> 0 Overfill prevention(see LG letter 150-1) 0 Other: see below <br /> J- <br /> -7 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDIS CURRENT HOURLY RATE. <br /> EHD Inspector: Received F-77 Title: <br /> C I <br /> EHD 23-04 <br /> 1/1/()7 <br />