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SAN JOAQUIN COUNTY It <br /> *ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor, Stockton,CA 95202-2708 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Inspection Date: <br /> Facility Name: 'o 42� nO#1 1 vo � ""D� Service RVe`n q'ues[#: <br /> Facility Address: 11 gt-I V r n <br /> TKO d• Owl Wa V W <br /> Onsite SerX1 T <br /> cc echnician's Name: ICC Service Tec ' w nnstaller CertificaCo #: anufacturer Training: <br /> u avi, <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ hlcon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> 11 ❑ mechanical Model: [01 ❑ 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 /> S sensor �L Primary piping testing at: <br /> positshutdown Model: ❑ psi <br /> fail safe Serial#: 1,0minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fall safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) 1 Piping <br /> ❑ fall safe Serial#: Sump(s) UST(s) <br /> ❑ NA <br /> ❑ Drop tube with mechanical overfill at 95% ffEl0ther: <br /> old start of monitoring panel <br /> ❑ Drop tube with mechanical overfill at 95% orrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) see below <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> Received Title: / <br /> EI- inspect c {e�7 r I C I <br /> 1-1 11)33-04 <br />