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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENI <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgov.ore/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Servic Reque t#: <br /> b4-25- 54 AcnSz-q� 60 <br /> Onsite Service Technician's Name: I C Service Techniciantinstaller Certification#: Manufactuurr'err Training- <br /> 011 <br /> rng: <br /> J Sti� <br /> M�1rO <br /> C �l � S Cl— 1 <br /> SERVICE SERVICE <br /> Leak detector G <br /> ❑ mechanical Model: 37 Spilf bucket &minimum 5 gallon <br /> ❑ X El hour hydrostatic E'Incon TS-STS <br /> El electronic Serial#: 11 Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector <br /> il <br /> Elmechanical Model: 91 Spi1 bucket 4 minimum 5 gallon <br /> ❑ ❑ electronic Serial#: ❑ 1 hour hydrostatic ARL Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <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 programmed <br /> sensor Primary piping testing at: <br /> ❑ [I positive shutdown Model: ❑ si <br /> 11 fail safe Serial#: p <br /> El NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: { psi <br /> El fail safe Serial #: minutes <br /> I] NA <br /> sensor Secondary containment repairs for: <br /> 1-1 El positive shutdown Model: UDC(s) Pi in <br /> ❑ fail safe Serial#: ( ) p g <br /> ❑ NA 9 <1/mak 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 /> El Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> u kk, IDe- "/540- a �7 <br /> lr�l -kv, '� s A 7 >w <br /> c 1 e Gl Cl[i // ti <br /> er $ VSs l <br /> i I/� 1L r i Gc� s X74 SS7 SU aecP <br /> THIS FACILITY IS SUBJECT TO REINSPE TION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspecto Received By: _ Title: <br /> t <br /> EHD 23-04 <br /> Rev 06/22/07 <br />