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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMFT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigoy.or ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Fac'ity Name: Inspection ate: <br /> 11IS101 <br /> ✓ <br /> Faci ity A dress: Servic Req est <br /> 5 law✓ aD51q[�0 <br /> ZOR�eSe vi <br /> ce Tech cian's Name: ICC Service Technician/installer Certification#: Manufacturer T arcing: <br /> v VlVlll� GlI Z, '1 I'l? q vte�c1��✓, <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 <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial : ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum.5 gallon <br /> ❑ <br /> El electronic Serial ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> ❑ Caldwell System 11 Other <br /> ❑ line testprogrammed <br /> sensorPrimary piping testing at: <br /> El k4itive shutdown Model: �� �Q� j,470 } ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> El NA <br /> m sensor <br /> f Secondary piping testing at: <br /> ❑ positive shutdown Model: V- u ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor <br /> ❑ positive shutdown Model: �(�10 Secondary containment repairs for- <br /> El <br /> safe Serial #: El UDC(s) Piping <br /> El 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 /> oil L <br /> t � aln 5 <br /> Inn+ AK vc In uvs Vf I oS S �S <br /> r ,' u I'�S c I4 I' i Y 'v V V+ A l It e <br /> I t o V 1lot <br /> THIS ACILITY IS SUBJECT YOItEINSPEQTION AT ANY TIME T EHD'S CURRENT HOURLY RATE. <br /> E D Insp or: R eiv 7 itle: <br /> �n <br /> EHD 23-04 <br /> Rev 06/22/07 <br />