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SAN JOAQUIN COUNTY <br /> ONVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sieov.or0 ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: [asp n Date: <br /> Facility Addr / /x/1/1 /;, ,,/- Service Request#: <br /> Onsite Service Technician's Nam: ICC service Teehdd ■tatter Certiflcation 4: Manufacturer Training: <br /> v/r'VVv <br /> SERVICE SERVICE <br /> Leak detector <br /> 1:1 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> 11C10 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <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: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Primaps pi testing at: <br /> ❑ fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ si <br /> El fail safe Serial#: p <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> 1-1fail 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 /> Vt„l <br /> w /� - <br /> �Q � <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIM T SiURRENT HOURLY RATE. <br /> EHD In tor: Received By Title: <br /> EHD 23-04 - - <br /> Rev 06/22/07 <br />