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iSAN 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.sieov.oreichd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> C t- � INq �'�Q �� 3 b <br /> vice equest <br /> Facility Address: Ser #: <br /> Onsite Service Technician's Name: ICC ServiceTechnician/installer Certification#: Manufacturer Training: <br /> v a rJ Z51 rig ID-) V Q--j /v <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: El — si <br /> El fail safe Serial #: p <br /> minutes <br /> 11 NA <br /> sensor <br /> El positive shutdown Model: Secondary piping testing at: <br /> E] ❑ fail safe Serial #: ❑ psi <br /> El NA minutes <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: <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 /> n h1 ` 1G G 67 �-n <br /> A1l <br /> e of FL _( �7 34 f� <br /> VD2 rAY K) V,/q r- 4 5n s <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E/9 Inspector: Received By: �J Title: <br /> VjAj /CG4 e Cie. <br /> EHD 23-04 <br /> Rev 06/22/07 <br />