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6 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.sjgov.orglehd <br /> UNDERGROUND STORAGE TANK(USTI PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 4 It& 6,q -,7- pi.-- <br /> Facility Address: Service ItequestW: V <br /> 16t2. ...•-4- L 0%1 <br /> Onsite Service Technician's Name: [CC Service Technician/Installer Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector 0 electronic Serial -Spill bucket 0 minimum 5 gallon <br /> ❑ 0 mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> ® Caldwell System 0 Other <br /> LOL line e t=es t roEammed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El 0 mechanical Model: 0 F-1 I hour hydrostatic El Incon TS-STS <br /> 0 electronic Serial El Caldwell System 0 Other <br /> 0 line test proEammed <br /> . Leak detector Spill bucket El minimum 5 gallon <br /> 0 mechanical Model: <br /> 0 electronic Serial #: 0 D I hour hydrostatic El Incon TS-STS <br /> pgrammed El Caldwell System 0 Other <br /> El line test ro <br /> sensor Primary piping testing at: <br /> 0 positive shutdown Model: F-1 psi <br /> 0 fail safe Serial#: minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ El positive shutdown Model: 11 -psi <br /> El fail safe Serial #: minutes <br /> DNA <br /> sensor Secondary containment repairs for: <br /> ❑ D positive shutdown Model: 0 UDC(s) Piping <br /> D fail safe Serial sump(s) UST(s) <br /> El NA <br /> ❑ Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> Drop tube with mechanical overfill at 95% El Corrosion protection <br /> 11 <br /> Ewverfill prevention(see LG letter 150-1) Other: see below <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: R eived By f Title: <br /> ry <br /> EHD 23-04 <br /> M-1 na/131)ln-7 <br />