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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 Fax: (209)468-3433 Web:www.sjgov_.or <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> �-- ; 2 v� <br /> Facility Address: Service eque #: <br /> g606 -4, 12X <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Certification#: Man f turer Traini <br /> M1'9 I=g: 4 <br /> Jc► 74-' fz-4 '576 -147'x- 6 \/ f'^A-qll 3G- t� <br /> SERVICE SERVICE <br /> Leak detectorL"J <br /> Spill bucket `Sd inimum 5 gallon <br /> mechanical Model: vim' �?�� , >;1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: �.. El Caldwell System El Other <br /> El 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 /> jKg sensor 4Lo-7 <br /> Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> il safe J Serial #: &7% y; El psi <br /> A minutes <br /> Za <br /> s <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> 1:1 fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ Elpositive 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% ;F?gt Corrosion protection —yc, ,�,Q v„ b ,- <br /> Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> Pte. Gt�2� 1 15 v a 1'� ^ /� <br /> 16 41,l- -s -b-f re— t✓4–&, GY S, <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME A EHD'S CURRENT HOURLY RATE. <br /> EHD InspectoRec y: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />