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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.sjgoy.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> F Inspection Date: <br /> Foci ft Address� ' Service Request 0: <br /> '3zfjN ,n o )e4Gu��*00Q <br /> 0.118" Service Technklan's Name: #CC Service TechniclaMrrstsller Exp.Date: 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 testpro <br /> rammed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑mechanical Model: <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test pMMmed <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 /> El fail safe Serial#: minutes <br /> ❑NA <br /> sensor Secondary containment testing for: <br /> ❑ ❑positive shutdown Model: UDC(s) Piping <br /> ❑fail safe Serial#: Sump(s) UST(s) <br /> ❑NA ❑ <br /> sensor Testing for the above components are next due by: <br /> ❑ ❑positive shutdown Model: <br /> ❑fail safe Serial#: Nm: PWm to wi"Wt r cx"Ywd cw pamft aro requW to to WwW upon <br /> ❑NA In"a6m,6 mortft after,and.vary 35 awnft ftmwfter. <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) I$ Other. see below s ` <br /> 4J'+k,leseg.A.Ad A-IlArLA 'n ". rojj f ke <br /> O e1 kP kj W& r'rN cwl� n e t� <br /> o � � , <br /> Q r It <br /> r 60 IF Is <br /> 411166W ®Y 'r ✓ <br /> THIS FACILITY IS SUBJECT TO REINSPECTIONAT ANY TIME AT EHD`S CURRENT HOURLY RATE. <br /> EHDI or: Tile: <br /> EHD 23-04 UST SERVICE REQUEST INSPECTION REPORT <br /> Rev 11/171/06 <br />