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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.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> Ir W �� � 211 <br /> -A va <br /> Facility Address: Service Request#: <br /> 32 2 S. 62 �,e �' , ��c,� S� D� s ZU <br /> Onsite Service Technician's Name: [CC Service Technician/Installer Certification#: Manufacturer Training: <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 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#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ si <br /> ❑ fail safe Serial#: p <br /> minutes <br /> El NA <br /> sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> ❑ <br /> 1:1 fail safe Serial#: 11 psi <br /> minutes <br /> El NA <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 /> 726�1�r_, , 'O"n V <br /> Cti°G, ',- L H ) v k ✓" /^L <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E spector: Received By: Title: <br /> v>� <br /> EHD 23-04 <br /> Rev 06/22/07 <br />