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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2708 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> i < 1/1 <br /> (S � I 0 <br /> Facility Address: ServIce Aquist#: <br /> 1�Vy GG' M&w ) S uU <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer raining: <br /> O <br /> 6 e U y�IrS f Vq4/0 ' U 5 # 69 QV 1141,11 <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial : 11 ❑ 1 hour hydrostatic Elhicon TS-STS <br /> El Caldwell System ❑ Other <br /> El line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> ❑ <br /> El electronic Serial#: El El hour hydrostatic [I Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> El mechanical Model: <br /> ❑ ❑ electronic Serial #: El El hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> 11 Caldwell System ❑ Other <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#: minutes <br /> ❑ NA <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% Corrosion protection I etx y lbw <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> yy! wfoldlivi oAkvi o ✓t ✓ I ✓ III LAaQ . <br /> D t • S l � <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EH p Inspec r: Received By: Title: <br /> EHD 23-04 <br /> 1/3/07 <br />