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SAN JOAQUIN COUNTY <br /> OVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sieov.orwehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> r,t" IS L-lQ Aolr 41161 o a <br /> Facility Address: Ct /1 Service Request#: <br /> IX19,g IJ�n 9ZO-U S 61 71 <br /> Onsite Service Technician's NO= We Service Technician/Installer Certification#: Manufacturer Training: <br /> Gavict 3 o rr, szoo o-7 - ur VR - ull?nk�3 <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 <br /> El positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> El fail safe Serial #: p <br /> minutes <br /> ❑ NA <br /> sensor <br /> ❑ positive shutdown Model: ❑ Secondary piping testing at: <br /> si <br /> ❑ fail safe Serial#: p <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 /> - velv� ' C EV2 UgPA - tyb tID Lj4qjrrLCL - <br /> - t� <br /> THIS FACILITY IS SUBJECT TO REINSPE TION AlhANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector <br /> '^^ n ,^ R ed By: Title <br /> vY l s lvv <br /> 1 A4 <br /> EHD 23-04 <br />