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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/chd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> I 1 j / 0 <br /> Facility Addr s: C3 <br /> /� Sery ce Re uest#: <br /> S 2 1 /'1�7w� <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: q I vc„1 <br /> 1,Jt e t -7 1 °v <br /> SERVICE SERVICE <br /> Leak detector , <br /> 1 Spill bucket El minimum 5 gallon <br /> ❑ ❑ mechanical Model: El hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: 2-2.Spill bucket El minimum 5 gallon <br /> 11 )i El hour hydrostatic ❑ Incon TS-STS <br /> 11 electronic Serial <br /> 1:1 line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector Dic,3 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: ❑ psi <br /> ❑ fail safe Serial#: <br /> minutes <br /> 11 NA <br /> sensor <br /> El positive shutdown Model: Secondary piping testing at: <br /> ❑ 13fail safe Serial#: ❑ psi <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial#: ( ) p g <br /> ❑ 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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S RENT HOURLY RATE. <br /> EHD Inspector: Receiv ry. Title: <br /> EHD 23-04 Vf <br /> Rev 06/22/07 <br />