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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.org''ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> kjAAM Aka,4q- 4 • I0 • Z)i� <br /> Facility Address: V Service Request#: <br /> C► 6006 <br /> S� 1 <br /> nsite Service T cian's Name: ICC Service Technician/installer Ce ►cation#: Man%Wtur Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> F1 Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> 1:1 mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial El 1 hour hydrostatic ❑ Incon TS-STS <br /> El Caldwell System ❑ Other <br /> El line test programmed <br /> Leak detector <br /> [I mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> op 4 AjAf, sensor <br /> Primary piping testing at: <br /> ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> minutes <br /> 1:1 NA <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 <br /> i <br /> HIS FAq ITY IS SU JECT TO REINSPECTION ATA Y TIME AT EHD'S CURRENT HOURLY RATE. <br /> E 's rL Received Title: <br /> EHD 23-04 <br />