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SAN JOAQUIN COUNTY <br /> INVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjlrov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility e: Q" I. <br /> Date: <br /> baoA M l. /4-d <br /> Facility Address: Service Request#: <br /> 6(bll to 61VA <br /> Onsite Service Technician's Name: ICC Servic Technician/ staller Cc r ification#: Manufacturer Training: <br /> yff"12T- <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 /> O mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro ammed 11 Caldwell 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 /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ ❑ fail safe Serial#: ❑ psi <br /> minutes <br /> ❑ NA <br /> sensor <br /> ❑ ❑ positive shutdown Model: ElSecond Secondary piping testing at: <br /> ❑ fail safe Serial#: p <br /> minutes <br /> El NA <br /> sensor <br /> ❑ positive shutdown Model: Secondary containment repairs for: <br /> El El UDC(s) Piping <br /> ❑ fail safe Serial #: <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) ❑ Other: see below <br /> C <br /> eA - yow W <br /> V rtl <br /> THIS FACILITY IS SU JECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E o eiv y: Title: <br /> EHD 23-04 <br />