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SAN JOAQUIN COUNTY <br /> NVIRONMENTAL HEALTH DEPARTMENT it <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 /> Facility Add ss: Service Request#: <br /> wzsS 6 M00'" SpWckq- 1 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> C*-AjN younj G 5 a — CA ( diel YM TAWN/N6 <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 /> L1 mechanical Model: <br /> El <br /> El electronic Serial#: El El hour hydrostatic El Incon TS-STS <br /> El line test programmed El Caldwell System 11 Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> E] ❑ mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: El Caldwell System E] Other <br /> El line test programmed <br /> sensor <br /> F-1 El positive shutdown Model: Primary piping testing at: <br /> si <br /> El fail safe Serial#: C� p <br /> ❑ NA <br /> >t Z des t1K s <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> minutes <br /> 11 NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC s Pi in <br /> ❑ fail safe Serial#: ( ) _Piping <br /> Sumps) UST(s) <br /> El NA <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 /> —P"fca So- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION T ANY r ME AT D'S CURRENT HOURLY RATE. <br /> EHD Inspector , _ p Received By: Title: <br /> EHD 23-04 N <br /> 1/3/07 <br />