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100 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEO <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sieov.org/eh <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> WIN't MLVk 4-�- <br /> Fac-Tit—y Address:-A Service Request#: <br /> CA <br /> Onsite Service TecWcia ' ame: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> mechanical Model: I F-1 El I hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial #: X051! 0 Caldwell System El Other <br /> 0 line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> F1 mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: El Caldwell System 0 Other <br /> El line test programmed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> 0 mechanical Model: 0 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial #: 11 Caldwell System 0 Other <br /> 0 line test programmed <br /> sensor Primary piping testing at: <br /> 0 positive shutdown Model: D psi <br /> F� fail safe Serial #: minutes <br /> 0 NA <br /> sensor Secondary piping testing at: <br /> ❑ 0 positive shutdown Model: 0 psi <br /> 0 fail safe Serial #: minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ 0 positive shutdown Model: 0 UDC(s) Piping <br /> 0 fail safe Serial #: Sump(s) UST(s) <br /> 0 NA <br /> El Drop tube with mechanical overfill at 95% 0 Cold start of monitoring panel <br /> 0 Drop tube with mechanical overfill at 95% 0 Corrosion protection <br /> 0 Overfill prevention(see LG letter 150-1) 0 Other: see below <br /> L:— <br /> lopsI <br /> f I <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins!; <br /> re ved By: Title: <br /> R;L <br /> EHD 23-04 <br /> Rev 06/22/07 <br />