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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.sigov.orwehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fac''ty Name: � I �ection Date,AL+ C—uLs �s '�+- " K <br /> F ility Address-. S v�ceReguest�# <br /> � /bn / � ) <br /> rte ervice vTfchn'cia 's Name: [CC SeIce Teen r Certification#: Manufacturer Training: <br /> � v CoP gteu��C/ <br /> SERVICE SERVICE <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 <br /> ❑ mechanical Model: Spill bucket 1:1 minimum 5 gallon <br /> ❑ ❑ electronic Serial#: El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro ammed ❑ Caldwell System 11 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 /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> ❑ NA minutes <br /> sensor Sec9.ndary piping testing at: <br /> ❑ ❑ positive shutdown Model: psi <br /> ❑ fail safe Serial #: <br /> ❑ NA minutes <br /> sensor Sec ndary containment repairs for: <br /> ❑ ❑ positive shutdown Model: !� �p UDC(s) Piping <br /> ❑ fail safe Serial#: <br /> ❑ 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 /> oil <br /> THIS CI ITY IS'SUBJECf TO REINSPECTION AT A Y InME AT EHD'S CURRENT HOURLY RATE. <br /> EHD p o. Received y: Title: <br /> I V '& dvk Iq <br /> EHD 23-04LS r 1v•- <br /> Rev 06/22/07 S1 gr <br /> 1 <br />