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SEP-17-2007 10:11 Service Station Systems 408 938 8888 P.09 <br /> SAN JOAQUIN COUNTY <br /> ' F,NVIRONMENTAL HEALTH DEVARTMENI- <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www-sjgov.org[ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRA_Mi SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: , Inspection!Yate:' <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service Technician%Installer Certification#: Manufacturer Training: <br /> L <br /> SERVICE SERVICE <br /> Leak detector V <br /> C 6� ` �� Spill bucket El minimum 5 gallon <br /> mechanical Model: l El 11 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: C� 1 U L! �_ _ ❑ 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 progEammed <br /> Leak detector Spill bucket D minimum 5 gallon <br /> ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: p Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> F1 El positive shutdown Model: ElPrimas p piping testing at: <br /> si <br /> O fail safe Serial #: <br /> minutes <br /> 11 NA . <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: . ❑ _ psi <br /> El fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor <br /> ❑ positive shutdown Model: Secondary con ta ment repairs for: <br /> ElElsafe Serial #: El — C(s) Piping <br /> ❑ fa p( ) <br /> © NA UST(s) <br /> _�.,,.. �5um 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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT HD'S CURRENT HOURLY RATE. <br /> F,HD cctor. �1 RecCi By: � / / Titl` <br /> I <br /> EHD 23-04 <br /> RQv 06/22107 <br />