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SAN JOAQUIN COUNTY <br /> CNVIRONMENTAL HEALTH DEPARTMENT Vev, <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:wµvv--SjR0v,0r ehd <br /> UNDERGROUND STORAGE TANK UST) PROGRAM SERVICE REQUEST DaINSPECTION REPORT <br /> Inspection Facility Name: / f ICI os <br /> �S 112UC.IUNG Service Request#: <br /> Facility Address: <br /> , bitpoeT h�kt1 S�r,Ir mN <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> �2tG lUlo�FnitKo 57,.Cv200 u-i A1Pt1 34��3 rf tt�l�o� <br /> SERVICE SERVICCEE <br /> Leak detectorSt- Spill bucket l/minimum 5 gallon <br /> Cl ❑ mechanical Model: 11 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: El —psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ 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 /> A <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIMW EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> A4 . ►��2N <br /> EHD 23-04 <br /> Rev 06/22/07 <br />