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SAN JOAQUIN. COUNTY <br /> t NV IR()NME,IIll T,-.t,REA 14 TI DHTAkI M EiNT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.or /Q ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTI REPORT <br /> Fac'' Name: In ction Date: <br /> Gil VS fz-- v <br /> Facility ress: 61 Service Request#• / <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufact er T aI ing: <br /> 4 v� - <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: _ _ ill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 our hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> ❑ aldwell System ❑ Other <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 ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial <br /> ❑ line test ❑ <br /> programmed Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: _ ❑ psi <br /> ❑ fail safe Serial#: <br /> El NA minutes <br /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Secondary piping testing at: <br /> El safe Serial#' p <br /> El NA minutes <br /> sensor <br /> ❑ ❑ positive shutdown M el: ❑ Secondary containment repairs for: Piping <br /> ❑ fail safe 'al#: ( ) p g <br /> ❑ NA Sump(s) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ Drop tub ith mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill preve ion(see LG letter 150-1) ❑ Other: see below <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> EHD 23-04 <br /> Rev 06/2?/07 <br />