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SAN JOAQUIN COUNTY <br /> ?SVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> S2n0 5-7 t <br /> Onsite Service Technician's Name: ICC Service Tcehniciadtnstaller Certification#: Maaeot�urer I reining:7e- <br /> 12'j <br /> (— I,LJI$IJ5 <br /> ar.> 11 -31^V9 SII <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: ❑ 111 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 n <br /> sensor Primary piping testing at: Gt'154e..scr-*Z-- <br /> ❑ ❑ positive shutdown Model: 50 psi <br /> 1 <br /> ❑ fail safe Serial#: ;Z C> minutes 257, 1 <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: 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 /> re-4 <br /> c- e,Ss D;rffZ2Ui Wc-rL bi75tn�,-�. <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT#NY TIME AT EHD'S CURRENT HOURLY RATE. <br /> [EH <br /> D Inspecto R ei ed B �— Title: l <br /> / r-V <br /> EHD 23-04 <br /> Rev 06/22/07 <br />