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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 Fmx:(209)468-3433 Web:www.sieov.ore-elid <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: p Inspection ate: <br /> vR llti -1 Pq�� t7 Z �e�r� leuM seruic� lax`/ ( [ 0 , 1 <br /> Facility Address: � 'A 1 �� Service Request N: <br /> 3 Q S S . SZ o0.�6s3� <br /> Onsite Service Technician's Name: ICC Service Technicia Installer Certification#: Manufacturer Training: <br /> tAUU� U�/J er /Zoa�- <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> ❑ El mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: El Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket 1:1 minimum 5 gallon <br /> ❑ ❑ mechanical Model: El El hour hydrostatic ❑ Incon TS-STS <br /> E-1 electronic Serial #: El Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ El mechanical Model: ❑ El hour hydrostatic El Incon TS-STS <br /> 1-1 electronic Serial #: ❑ Caldwell System ElOther <br /> ❑ line test ro ammed <br /> sensor Primary piping testing at: <br /> El positive shutdown Model: <br /> ❑ <br /> El fail safe Serial #: Eli <br /> m <br /> 11 NA <br /> minutes <br /> sensor Secondary piping testing at: <br /> ❑ positive shutdown Model: <br /> F-1 <br /> 11 fail safe Serial #: El psi <br /> minutes <br /> El 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 /> DnSi Ver O�C r'�./ �'�J�`�tICE! -T-(,S 3 v r�o�i <br /> t . Ul l -l✓ l to ' br <br /> Lo rtrj� a T Aon Ce�Na I� <br /> ud C� re rtn i j, r <br /> ✓ n�oS S �, wC,c l41(� wrl� -1 <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E Inspector: Received By: Title: <br /> (/z#j loci I*Ck r✓ <br /> EHD 23-04 <br /> Rev 06/22/07 <br />