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0 SAN JOAQUIN COUNT" is <br /> ENV IR0NJvIb.P'ITAL14EALTF DEPARTMENT <br /> 600 Fast Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.orwehd <br /> UNDERGROUND STORAGE TANK ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> AIr�VO� -1 <br /> Facihltyt11-2-- <br /> Address: Servic Requ st#: <br /> l � ✓ ao &/$- <br /> Onsite Service Technician's Name: ICC Service Technician/lAaWW Certification#: Manufacturer Training: <br /> egoLb,, 2 <br /> SERVICE SERVICE <br /> Leak detector <br /> LJ mechanical Model: Spill bucket C-1minimumS gallon <br /> ❑ ❑ electronic Serial #: 0 ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: '` <br /> ❑ <br /> El positive shutdown Model: e>-J psi dim l? 9/ �# S7 jjL, <br /> ❑ fail safe Serial#: <br /> minutes <br /> El NA �Q �cQ � �' S'2 7 <br /> sensor <br /> ❑ Second F-1positive shutdown MModel: ❑ Secondary piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> 11 fail safe Serial#: ( ) p g <br /> El NA Sump(s) UST(s) <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 <br /> 02 <br /> i I <br /> THIS fAqILITY.I§ SUBJECT TO REINSPECTION AT M T EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector- Received By: Title: <br /> VP <br /> EHD 23-04 <br /> nmmln� <br />