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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.si>;ov.or /�ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facili N6me <br /> Inspection Date: <br /> Facility Address: Service Request#: <br /> S - QW6(4(QP [..4011) Sf( MS-5-1922 <br /> Ons __7 <br /> ite ' vic Technicia ame ICCvice Technician/installer Certification#: Manufacturer Trainin V r� <br /> ' V V J n I V <br /> SERVICE SERVICE <br /> Leak detector <br /> mechanical Model: Spill bucket El minimum 5 gallon <br /> electronic Serial F-1El1 hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> El ❑ electronic Serial : ElEl1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El 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 <br /> ❑ <br /> El shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑ fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor <br /> ❑ <br /> El shutdown Model: ❑ Secondary piping testing at: <br /> si <br /> ❑ fail safe Serial #: <br /> minutes <br /> ❑ NA <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 /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> 42 <br /> 'ti✓ <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: RC'L'( <br /> eceiv By: Title: ' <br /> czv I -- <br /> EHD 23-04 <br /> Rpv n6/9,?in7 <br />