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rl SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)4W3420 Fax:(209)468-3433 Web:www.siQoy.Orq/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> ` ` -UF0� Inspection <br /> FsdNty Address: Service Request*: <br /> py nklan's Now V ICC Service Tec Ienllnataller Exp.Dabs: Manufacturer Training: <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 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 /> �r 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 containment to n <br /> El ❑positive shutdown Model: UDC(s) Piping <br /> ❑fail safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> sensor Te ting f r the above components are next due by: <br /> ❑ positive shutdown Model: �ave?!btL❑ 41610❑fail safe Serial#: <br /> NM: Phw w.rw.thM r oardskumt camv«wms w•fGquww m ng rand upon <br /> ❑ NA InkWW .8 xW"ow,gra wwy 35 M&O"""Gftr. <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 /> N # <br /> e <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD InspedoI Td <br /> r. <br /> UST SERVICE REQUEST INSPECTION REPORT <br /> EHD 23.04 <br /> Rev 11/17/108 <br />