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• SAN JOAQUIN COUNTY a <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 304 East Weber Avenue,3rd Floor, Stockton,CA 95202-2708 <br /> Telephone: (209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/chd <br /> UNDERGROUND STORAGE TANK ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> W&V IF IN Abe 1 01 <br /> Facility Address: Servkce Request#: <br /> 1pshlvi Ifiq W07L05c17-7 <br /> Onsite Service Technician's Na e: ICC Service Technician/I Certification#: Manufacturer Training: <br /> &twul <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ hicon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial ❑ El hour hydrostatic ❑ hlcon TS-STS <br /> ❑ Caldwell System El Other <br /> El line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial ElEl1 hour hydrostatic 11hlcon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> Primary piping testing at: <br /> pos tive shutdown Mod 1: % 0'�11� ❑ psi <br /> fail safe Serial#: � (�'!� minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> 13 fail safe Serial #: ( ) p g <br /> 11 NA Sump(s) UST(s) <br /> ❑ Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> ❑ 1 Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ 1 Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> QVIM, m n> ik V <br /> Ink \P9 ytGjfi'ff'6 J <br /> THIS FACILIT IS SUBJECT Th REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E D Ins a tor: eived Tile: <br /> GCfHf ct4 <br /> EHD 23-04 <br /> I nina <br />