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SAN JOAQUIN COUNTY � <br /> ENVIRONMENTAL HEALTH DEPARTMEN i <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:www•sjg_ov.or&hd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> F ility Name: Inspection Date: <br /> 1114 <br /> Facility Address: Servi a l4equest#: <br /> T5W VV- owner 140 51 o <br /> On 'te service Technician's Name: ICC Service Technician/installer Certification#: nuTacture T aining: ,v <br /> ntaw►��C� '.w�a� � � <br /> ✓ II N 17 0 <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 ❑ 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 /> politive shutdown Model: 0 Wed ❑ psi <br /> fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor <br /> ove shutdown Model: Lh 'V A (�0l" Secondary piping testing at: <br /> Serial #: El psi <br /> Zailsafe <br /> minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> positive shutdown Model: Ull:-) U IV ❑ UDC(s) Piping <br /> faiI safe Serial #: { ) p g <br /> ❑ 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 /> 1 ri �t a� <br /> LK d t V frn �vl r ` <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME T EHD'S CURRENT HOURLY RATE. <br /> E D Instor- Received Title: <br /> �f <br /> EHD 23-04 <br /> Rev 06/22/07 <br />