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i <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far.(209)468-3433 Web:www.sigov.ore/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> FacilitU�4 <br /> Inspection Date: <br /> 6A S-'277- 01 <br /> Fac'ity Address: Service Request#: <br /> Jt CN Cod r ,W, <br /> Onsite Service Technician's Name: [CC Service Technician/installer Certification#: on (a arer Training: <br /> P,�1 ISN �++�. N �E I 2-�ie <br /> SERVICE SERVICE <br /> Leak detector Spill bucket <br /> ❑mechanical Model: P l� minimum 5 gallon <br /> ❑ ❑ electronic Serial#: 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical Model. Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model. El 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#� <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> sensor <br /> O positive shutdown Model: Primary piping testing at: <br /> El ❑ID fail safe Serial#: psi <br /> [I NA minutes <br /> sensor <br /> [I positive shutdown Model: Secondary piping testing at: <br /> El ❑ fail safe Serial#: ❑ psi <br /> ❑ NA minutes <br /> sensor Secondary containment repairs for: <br /> ❑ ❑positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial#: Sump(s) UST(s) <br /> ❑ 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 /> O Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> 0 ' � °► ; `N �( l hr <br /> N �r <br /> THIS FACILITY IS SUBJECT TO REINSPE TION AT ANY TWE#f EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector Recei Title: <br /> r <br /> EHD 23-04 <br /> Rev 06/22/07 <br />