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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.sigov.org/eh <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facil' Name: Inspection Date: <br /> nym %ell 11 111V <br /> Facility Ad ress: Se" a equ t#: <br /> 4I d le <br /> Onsite Service ec 'clan's Name: ICC Service Technician/Installer Certification#: ,gaa� ra <br /> ct a Tining: <br /> m�alae 51 S' u S U kill lk� <br /> SERVICE SERVICE <br /> �O$ Leak detector <br /> Spill bucket 11 minimum 5 gallon <br /> mechanical Model: �j1/0� ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: III OV101 ❑ 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: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> E] NA minutes <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) 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% rElcother: <br /> orrosion protection <br /> ❑ Overfi� 111 prevention(see LG letter 150-1) see below <br /> /ga Vt/ (A,S �J PrS <br /> THIS FACILITY IS SUBJECT TO REINSPECTION A ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Ins tor: Rece'v y: Titf <br /> EHD 23-04 <br /> Rev 06/22/07 <br />