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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.sjjzoy.or-g/eh <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 7- cam 1 / 2. Zloci <br /> Facility Address: Service Request#: <br /> /30t1 N (M hfkf S% IM^�� 946 6 � Z 7 <br /> Onsite Service Technician's Name: [Cvic T chnician/Installer Certification#: anufacturer Training: <br /> S 2� GI c� Z 1�-�- T /'13// 3 / "Vol <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial El 1 hour hydrostatic ElIncon TS-STS <br /> El Caldwell System ❑ Other <br /> El line test programmed <br /> Leak detector <br /> 11 mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial ❑ El hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El 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 /> El shutdown Model: Primary piping testing at: <br /> F1 <br /> El fail safe Serial #: ❑ psi <br /> minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: <br /> El NA 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 /> ❑ Overfill prevention (see LG letter 150-1) FT Other: see below <br /> nC <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rece ed By: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />