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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENO <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> A 7 �� 1 - <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: LCC Service Technician./Installer Certification#: Manufacturer Training: It 0 3 C-33 <br /> 5�ve� <br /> 0 C�l C52-5,';'1b3- U7-, 0-fl- te-,x4 2-3 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> El mechanical Model: El 0 1 hour hydrostatic El Incon TS-STS <br /> F-1 electronic Serial #: El Caldwell System 0 Other <br /> 0 line test programmed <br /> Leak detector Spill bucket R minimum 5 gallon <br /> ❑ El mechanical Model: F1 0 1 hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: 0 Caldwell System 0 Other <br /> El line test programmed <br /> I Leak detector -Spill bucket F-1 minimum 5 gallon <br /> 0 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> El electronic Serial El Caldwell System 0 Other <br /> 0 line test programmed <br /> sensor Primary piping testing at: <br /> 0 0 positive shutdown Model: El psi <br /> 0 fail safe Serial#:A <br /> El minutes <br /> N <br /> sensor Secondary piping testing at: <br /> 0 0 positive shutdown Model: ❑ psi <br /> F� fail safe Serial <br /> El NA minutes <br /> sensor Secondary containment repairs for: <br /> 0 0 positive shutdown Model: 0 DC( ) pingEl fail safe Serial #: Smp(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 /> Overfill prevention(see LG letter 150-1) El Other: see below <br /> zu/:5-- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHDS CURRENT HOURLY RATE. <br /> EHD Inspector: Received 5y: Title: <br /> 7 7-- <br /> EHD 23-04 <br /> Rev 06/22/07 <br />