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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTM <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sieov.org/ehd <br /> UNDERGROUND STORAGE TANK ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 7— C \) 21 Z91, Og <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> �i2VlGt <br /> STet-s'asf I /CMS 52LO92 —UT V9 H 31131 <br /> SERVICE SERVICE <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 ❑ 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 ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> ❑ positive shutdown Model: Primary piping testing at: <br /> ❑ ❑ fail safe Serial#: El Primary <br /> ❑ NA minutes <br /> sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> ❑ ❑ fail safe Serial#: Elpsi <br /> ❑ NA minutes <br /> sensor <br /> ❑ positive shutdown Model: Secondary containment repairs for: <br /> ❑ ❑ fail safe Serial #: ❑ UDC(s) Piping <br /> ❑ NA Sump(s) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% IV Cold start of monitoring panel Fog evC PIW& <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ElOverfill prevention (see LG letter 150-1) ❑ Other: see below <br /> 40 OUT S z- 04AT IR <br /> Lr � r�Np u3 8�i�g1 Flu u,>7PS �/Lv/GE �a �-✓� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector '^ Received By: Title: \ <br /> EHD 23-04 <br /> Rev 06/22/07 <br />