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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:yn3LNy <br /> _.Ajgoy.org/ehd <br /> UNDERGROUND STORAGE TANK (UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: <br /> Inspection Date. <br /> Facility Address: Service Request#: <br /> -.7 <br /> Onsite ServiceTechnician's Name: ICC Serviee Tek)hnician/Installer Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> D -mechanical Model: Spill bucket El minimum 5 gallon <br /> El E] electronic Serial #: El El i hour hydrostatic El Incon TS-STS <br /> El line test programmed 0 Caldwell System 0 Other <br /> Leak detector —Spill bucket El minimum 5 gallon <br /> ❑ El mechanical Model: El El I hour hydrostatic El Incon TS-STS <br /> El electronic Serial F-1 Caldwell System 0 Other <br /> 0 line test programmed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El El mechanical Model: El 0 1 hour hydrostatic El Incon TS-STS <br /> 0 electronic Serial El Caldwell System 0 Other <br /> El line test programmed <br /> '1—sensor <br /> positive <br /> Primary piping testing at: <br /> [I positiv"' shutdown Model El psi <br /> -fail safb Serial minutes <br /> 11 1 <br /> El NA <br /> sensor Secondary piping testing at: <br /> El El positiveshutdown Model: El psi <br /> 0 fall safe Serial #: minutes <br /> 0 NA <br /> sensor <br /> Secondary containment repairs for: <br /> [I posiflvz� shutdomm Model:44-1 <br /> I 1pi L6 <br /> 2M Serial #: Sump(s) UST(s) <br /> fa' safe <br /> El NA <br /> ❑ Drop tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> El Drop tube with mechanical overfill at 95% El Corrosion protection <br /> El Overfill prevention (see LG letter 150-1) L, Other: see below <br /> % <br /> THIS FACILITY IS -5--jECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: RcFeiv4 By 12 Title. <br /> EHD 23-04 <br />