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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sSlgov.or /�ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 1+1z,/A?2 <br /> Facility Address: Service Re est#: <br /> 1612- u -<�32oo 5'61 <br /> Onsite Service Technician's Name: CC Service Technician/installer Certification#: Manufacturer Training: <br /> � - l�C' X l opw x-Z /C> <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El El❑ electronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> F-1 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial : El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> ❑ El shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑ fail safe Serial#: p <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> El ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> minutes <br /> E] NA <br /> sensor <br /> El ❑ positive shutdown Model: El Secondary containment( )repairs for: Piping <br /> ❑ fail safe Serial#: ( <br /> Sump(s) UST(s) <br /> ❑ NA <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% Corrosion protection $7 Lj/ ,'000,/s 11// <br /> ❑ 1 Overfill prevention(see LG letter 150-1) ❑ Other: see below 6• ��5 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EH NT HOURLY RATE. <br /> EHD Inspecto R ' ed By: Title: <br /> EHD 23-04 <br /> Rp„ng/99M7 <br />