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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:(249)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection te: <br /> CA �V A ev -6 212, <br /> ob <br /> Facility Address: Service Re4uest#: <br /> Onsite Service Technician's Name: ECC Service lFechni is Installer Certification#: Manufacturer Training: <br /> Mot La <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ <br /> El mechanical Model: ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> 11 electronic Serial #:line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ CaIdwell System ❑ Other <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ El hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: <br /> El line testroammed ❑ Caldwell System El Other <br /> sensor <br /> ❑ positive shutdown. Model: Primary piping testing at: <br /> ❑ ❑ fail safe Serial #: ❑ psi <br /> ❑ NA minutes <br /> sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> El fail safe Serial #: Elpsi <br /> ❑ NA minutes <br /> sensor Secondary containment repairs for: <br /> ❑ <br /> 11 positive shutdown Model: " UDC(s) Piping <br /> ❑ fail safe Serial #: <br /> El NA e •,f 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 /> SZASZ� Vuere— D k-----; <br /> �1 I vN`I Q Lpry 64( Fel �4 rn 41) <br /> so? it <br /> L6L 't ��ICAPL(, Q ed D-��6LA R lvukg� C) SbmP, 4 <br /> bJ- 49Z 2 <br /> THIS F CILITY IS SUBJE" T TO REINSPECTED AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E inspector. Received By: Title: <br /> n l <br /> EHD 23-04 <br /> Rev 06/22/07 <br />