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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)468-3433 Web:www.sjgov.org/eU <br /> UNDERGROUND STORAGE TANK{ UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> Vv v 22 16 <br /> Facility Address: Service Re nest#: <br /> 5-0 (A-),, G l< U s/M) 5S� 7 Z � <br /> Onsite Service Technician's Name: ICC Service Technician/installer Certification#: Manufacturer raining: <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 proEammed <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 <br /> ❑ mechanical Model: Spill bucket Elminimum5 gallon <br /> ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> positive shutdown Model: Zb�) ❑ psi <br /> 9 fail safe Serial #: ,T <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> El ❑ positive shutdown Model: ® UDC(s) Piping <br /> ❑ fail safe Serial #: <br /> 1:1 NA 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 /> ❑ <br /> Overfill prevention(see LG letter 150-1) Other: see below O 1 4'1-c) <br /> UM 10 <br /> ` ' <br /> 7� T el - �,,r— C/,n4� °� /U'L'll� �iAJ 7� <br /> Azo i— <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E inspector. � Received 13y: Title: <br /> 1 <br /> EHD 23-04 <br /> Rev 06/22/07 <br />