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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)468-34,13 Web:www.sjgov.orjz/eh <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspe tion Da_T ITINZ W. -GS <br /> Facility A ss: Service Request#: <br /> lCA <br /> Si`Qj s s <br /> Ons'te Service T h clan's Name: ICC Service Technician/nstaller Certification#: Man facturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ 1:11 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: El 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: E] Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ ❑ mechanical Model: El El hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #: <br /> El line test programmed El Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> ❑ ❑ fail safe Serial#: ❑ psi <br /> minutes <br /> E] NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> 1:1 fail safe Serial#: <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ Elpositive 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 /> e, <br /> SLS OVA4MR-' <br /> kM.. No Cil e� <br /> THIS FACT IS SUBJECT T(AEIN ECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec r eived By: ^ ` Title: <br /> J961_/r 11"09A)04616 <br /> EHD 23-04 <br /> Rev 06/22/07 <br />