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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siQov.orWehd UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT Facility Name: Inspectio Date: AR (-o # 5-clSo I� 08 Facility Address: 1 Service R nest#: W , re,/v► �- �L, SQL b Ec 00 S Ll2 Onsite Service Technician's Name: /�„ ICC Service Techni ian/Installer Certification#: Manufacturer Training: r r ` L ��`' r q V72 CPT � <,l SERVICE SERVICE Leak detector ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon ❑ ❑ electronic Serial #: ❑ El hour hydrostatic ❑ Incon TS-STS El Caldwell System ❑ Other ❑ line test programmed Leak detector El mechanical Model: Spill bucket El minimum 5 gallon El ❑ electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS ❑ Caldwell System ❑ Other ❑ line test programmed Leak detector ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon : ❑ ❑ electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS El line test programmed ❑ Caldwell System ❑ Other sensor ❑ ❑ positive shutdown Model: ❑ Primary piping testing at: si ❑ fail safe Serial #: p I minutes El NA sensor Secondary piping testing at: El positive shutdown Model: ❑ psi ❑ fail safe Serial #: minutes El NA sensor Secondary containment repairs for: ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping ❑ fail safe Serial #: Sump(s) UST(s) ❑ NA ❑ Drop tube with mechanical overfill at 95% Cold start of monitoring panel ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below i v qf-i oE re l4- '9L seo"' - �, L4S S1 P L f hrn A M, 1, 10 -11 Se �w THIS FACILITY IS SUBJECT TO REIN PECTIO IS CURRENT HOURLY RATE. E Inspector: Receiv Title: �. van t-,, I of -c AVU�" UP,f7l EHD 23-04 p � De..ncu—"/n17 .