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V SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME�r <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:wwwgov.or ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspect' Date: <br /> C��("I Nl Lf FA�f h <br /> Facility Address: Service ¢quest#: <br /> ° W , C 4r �'� 26v GI <br /> nsi[ Service echnician's Name: ICC 7vice T hpicianlinstaller Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector AA <br /> mechanical Model: RCI.0)za" Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ electronic Serial #:( ,(� El Caldwell System ElOther <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 /> 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 /> 11 fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> 11 fail safe Serial #: <br /> 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 <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> ¢ 4dx F 14 (, <br /> THIS FACILITY IS SUBJECT TO REINS CTI N AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EH pector: eceived y: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />