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'ice 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:w .sjliov.ori7Jehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Ute- rv1 G{ I 4.r'l.1f 2—C:) C� <br /> Facility Addr s: Service Request#: <br /> 'S"/L o 0564 7 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> ter► t..J� C I'"�'' lti 16 64 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro ammed ❑ 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 ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ ancon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> 0 positive shutdown Model: Primary piping testing at: rcf—( <br /> ❑ ❑ fail safe Serial #: -51--psi <br /> ❑ NA hL,;, minutes <br /> sensor Secondary piping testing at: <br /> ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> 11 NA <br /> sensor Secondary containment repairs for: <br /> ❑ positive shutdown Model: UDC( ) 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%0 ElCorrosion protection <br /> ❑ Overfill prevention {see LG letter 150-1) ❑ Other: see below <br /> VW-!� <br /> THIS FACILITY IS SUBJECT TO REINSP,F.qTIOAT ANX TIM ATE D'S CURRENT HOURLY RATE. <br /> EHD Inspecto eceiv By: Cilie: <br /> EHD 23-04 Xwwvou <br /> Rev 06/22/07 <br />