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iSAN JOAQUIN COUNTY i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 - <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sipov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspe tion Dat PNA <br /> A(ZLO - Sal a <br /> Facility Address: �N Service Requ t#: <br /> vv fw� � �S���IL fZ 60S <br /> Onsite Service Technician's Name: ICCS vice hnician/Installer Certification#: Manufacturer Traini : <br /> pSr--, cj�r rtes(,b I l0 A- l U 2-'1/ <br /> 7 lib <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ 111 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <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 Spill bucket 11 minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> 11 electronic Serial#: <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> al 'I i k 5°1' ensor <br /> ❑ positive shutdown Model:' �� 39qPrimary piping testing at: <br /> ❑ fail safe Serial #:j� ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> ❑ NA minutes <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <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 /> n S i V Q1 <br /> �en IAIN <br /> 1- ro UOL <br /> 1✓l Qn i e►s <br /> THIS FACILITY IS SUBJECT TO REINSPEC1rION AT ANY TIM AT EHD'S CURRENT HOURLY RATE. <br /> EHD In ector: Received By: Title: ' <br /> EHD 23-04 \ <br /> Rev 06/22/07 <br />