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SAN JOAQUIN COUNTY It <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sieov.orQ/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit Name: Inspection Date: <br /> Facility Address: A Service Request#: <br /> 17 I S i C�c �S" y� 5S72� <br /> Onsite Service Technician's Na ICC Service Technician/installer Certification#: Manufacturer Training: <br /> i� NW '�8"16 V �3 2- ) -16 <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 ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> El Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> ❑ El psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ 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) I Other: see below? INQ! <br /> 2 <br /> THIS FACILITY IS SUBJECT TO REINSPECTIONAT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD InspReceived By Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />