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SAN JOAQUIN COUNTY <br /> 6 ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.siQov.or¢/ehd <br /> UNDERGROUND STORAGE TANK ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date- <br /> Sq 4--1 1=1.1-1 9 - o ;WC) 8 <br /> Facility Address: Serv' a Request#: <br /> Onsite Service Technician's Name: 1 Service Technician/Installer Certification#: Manufacturer Training: <br /> M." V—X- jew�/ <br /> SERVICE SERVICE <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 /> 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 /> 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 /> ❑ ❑ positive shutdown Model: ❑ si <br /> El fail safe Serial #: p <br /> minutes <br /> 11 NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: El — si <br /> El fail safe Serial#: p <br /> minutes <br /> 11 NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Pi in <br /> ❑ fail safe Serial#: ( ) p g <br /> Sump(s) UST(s) <br /> 11 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 /> t)k r-- <br /> THIS FACILITY IS SqPJECT TO REINSPE ION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: By: Title <br /> EHD 23-04 <br /> Rev 06/22/07 <br />