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0 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.or /g ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> C;,OgC �t 151 <br /> Facility Address: Service Re uest : <br /> i b I Z �4y <br /> Onsite Service Technician's Name: 1 ICC Service Technician/Installer Certification#: Manufacturer Training. <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ El electronic Serial ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> 1:1 Caldwell System ❑ Other <br /> Leak detector <br /> F1 mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 El❑ electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial El 1 hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed <br /> 11 Caldwell System ❑ Other <br /> sensor <br /> ❑ <br /> El shutdown Model: ❑ Primary piping testing at: <br /> si <br /> 1:1 fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor <br /> Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: �i Gf;-s psi 2 P o <br /> ❑ fail safe Serial <br /> ❑ NA 60 minutes <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 /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) Other: see below f` <br /> �G <br /> 1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Insp r: Received By: Title: <br /> 11''A'lJ <br /> EHD 23-04 <br /> Rev 06/22/07 <br />