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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.sjgoy_org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Servi a Req est#: <br /> 4 419 LI) !S-k 005Y- -24 <br /> Onsite Service Technician's Name: ICC S,e.,r,.vi k To(`hnlician/InstallleerCertifiication#: Manufacturer Training: <br /> RIS ',..r��."J l �'�iv��.s.i""^ fiG✓�OvD <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 /> '7 sensor <br /> El positive shutdown Model: D7Qjo Primary piping testing at: <br /> ❑ psi <br /> fail safe Serial #: 71l000 <br /> 5�z1 <br /> ElNA Iq 13� �� rY q — minutes <br /> sensor C' <br /> El positive shutdown Model: Secondary piping testing at: <br /> ❑ ❑ i <br /> El fall safe Serial #: psi <br /> ❑ NA minutes <br /> 10 <br /> ' .�►.y►l r- sensor l rz5'411 <br /> poLJ sitive shutdown Model. — �j Secondary containment repairs for: <br /> ail safe Serial #: v 700 ❑ S DC(ss 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 /> (J no(-.c r <br /> R'1 .•� 41.- <br /> 4z>r- - <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: TE Lu <br /> 0,0y <br /> EHD 23-04 <br /> Rev 06/22/07 <br />