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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (9venue, oo , Stockton,CA 95202-2708 <br /> Telephone: (209)468-3420 Fac:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Rale �� Ue-b S4�-io t-j -O ?Sc <br /> Facility Address: Service Request#: <br /> L11 .55 f . MOrA LW4 00 03 (-(2 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: 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 ❑ hicon 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 ❑ hicon TS-STS <br /> C� electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> �— Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial#: <br /> minutes <br /> ❑ NA <br /> sensor <br /> ❑ <br /> El shutdown Model: El Secondary piping testing at: <br /> si <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Pi in <br /> ❑ fail safe Serial#: ( ) p g <br /> 11 NA Sump(s) UST(s) <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 /> I 4j ri N U (Ar- Se^ 4 bU 2rV'nvie' <br /> p <br /> R 0�� IrY � I U W#-L A-r Av <br /> Inoe <br /> r✓ <br /> THIS FACILITY IS SUBJECT TO REINSPECTI ANY TIM T EHD'S CURRENT HOURLY RATE. <br /> EHD I ector: _ Rece' d Title: <br /> V►NI 1.�. <br /> EHD 23-04 <br /> 1/3/07 <br />