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0 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.-(209)468-3433 Web:www.sigoy.orehd <br /> UNDERGROUND ST TANK JUST) PROGRAM SERVICE R QUEST INSPECTION "PORT <br /> Facility Name: Inspection Date: <br /> ,W1 S <br /> �61 <br /> Facility Address: Service Request#: <br /> 12-Apb"7 <br /> PON <br /> Onsite Service Technician's Nam Technician/Installer ICC Service Tee Certification#: Manufacturer Training: <br /> JCST-lKt 5311 LA <br /> SERVICE SERVICE <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> 0 0 mechanical Model: ❑ 0 1 hour hydrostatic 0 Incon TS-STS <br /> D electronic Serial#: El Caldwell System 0 Other <br /> 0 line test programmed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> 0 0 mechanical Model: ❑ 0 1 hour hydrostatic El Incon TS-STS <br /> 0 electronic Serial E-1 Caldwell System 0 Other <br /> 0 line test programmed <br /> . Leak detector Spill bucket 0 minimum 5 gallon <br /> 0 0 mechanical Model: 0 0 1 hour hydrostatic El Incon TS-STS <br /> El electronic Serial#: 0 Caldwell System El Other <br /> 0 line test 2roEammed <br /> sensor Primary piping testing at: <br /> 0 0 positive shutdown Model: 0 psi <br /> 0 fail safe Serial#: minutes <br /> 0 NA <br /> sensor Secondary piping testing at: <br /> 0 0 positive shutdown Model: L p <br /> DNA si <br /> 0 fail safe Serial #: minutes <br /> sensor Secondary containment repairs for: <br /> 0 0 positive shutdown Model: 11 UDC(s) Piping <br /> 0 fail safe Serial#: Sump(s) UST(s) <br /> 0 NA I <br /> El Drop tube with mechanical overfill at 95% 0 Cold start of monitoring panel <br /> 1 D Drop tube with mechanical overfill at 95% 0 Corrosion protection <br /> 0 Overfill prevention(see LG letter 150-1) Other: see below <br /> Gc 2O <br /> — AnA 1.4 <br /> THIS FACILITY IS SUBJECT TO REINSPECT14DMAT ANY TIME AT E 'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rxeiv By: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />