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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.sjgxov.or <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facilit�ame: Inspection Date: <br /> d� Il — 12- 06 <br /> Fac'' Addres : Service Request#: <br /> ')-qbJ (&)k <br /> Onsite Service Technician's Name: ICC Service Technician/installer Certification#: Manufacturer Training: <br /> 144A1rV1 �.- Ll 19tM <br /> SERVICE SERVI <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial El El hour hydrostatic ElIncon 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 /> ❑ ❑ electronic Serial Ll El 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 /> ❑ El electronic Serial El El hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> F1 El shutdown Model: ❑ Primary piping testing at: <br /> si <br /> El fail safe Serial #: p <br /> ❑ NA minutes <br /> sensor <br /> ❑ Second❑ positive shutdown Model: El psi piping testing at: <br /> El fall safe Serial #: p <br /> ❑ NA minutes <br /> sensor <br /> Secondary containment repairs for: <br /> El positive shutdown Model: <br /> ❑ El fall safe Serial #: ❑ 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 /> IMWtk W j- 4& y <br /> � w <br /> 1 <br /> AJL wx ► }— +i <br /> KCInspe <br /> HIS FACILITY IS SUBJECT REI E 10 T ANY TIME AT END'S CURRENT HOURLY RATE. <br /> ctor c B Title <br /> EHD 23-04 <br /> Rev 06/22/07 <br />