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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web: www.sigov.ortzie1i <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit Name: Inspection Date: <br /> ,5A 6A SON l - 01 <br /> Fac'ity Address: Service Request#: <br /> w 3 3W1 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: an fa turer Training:VV44— NAM <br /> -y� <br /> SERVICE SERVICE <br /> Leak detector <br /> 1:1 mechanical Model: Spill bucket � minimum 5 gallon <br /> El ❑ electronic Serial X2 � 1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> 11 Caldwell System El Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 <br /> El electronic Serial #: El 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System El Other <br /> El line test programmed <br /> sensor <br /> El shutdown Model: Primary piping testing at: <br /> ❑ <br /> El fail safe Serial #: ❑ psi <br /> minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> ❑ NA minutes <br /> sensor <br /> El positive shutdown Model: Secondary containment repairs for: <br /> ❑ El UDC(s) Piping <br /> ❑ fail safe Serial #: <br /> Sump(s) UST(s) <br /> El 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 /> OIC <br /> N or <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIPE AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: ��� ,- iA6 elTitle: <br /> 11 / <br /> S <br /> EHD 23-04 ` <br /> Rev 06/29/07 <br />