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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:w�vw.sjgov.orgiehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Addre : Service Request#: <br /> 611; 1 r /�l L)e L 00S <br /> Onsite Service Technician's Name: ICC S,grvice Technician/installer Certification#: Manufacturer Training: <br /> J _ 1 v14 s Le 3 x— Zl3 <br /> SERVICE SERVICE <br /> D,e-s&4 Leak detector \12- <br /> ❑ mechanical Model: WtPtSpill bucket El minimum 5 gallon <br /> ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial #: Hef d3D6 c� ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial ElEl1 hour hydrostatic ElIncon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket 1:1 minimum 5 gallon <br /> ❑ <br /> El electronic Serial ElEl1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> ❑ Caldwell System ❑ Other <br /> sensor <br /> F-1 El shutdown Model: ❑ Primary piping testing at: <br /> si <br /> 1:1 fail safe Serial #: p <br /> ❑ NA minutes <br /> sensor <br /> F-1 El positive shutdown Model: ❑ Secondary piping testing at: <br /> E] fail safe Serial #: p <br /> ❑ NA minutes <br /> sensor <br /> F-1 El positive shutdown Model: El Secondary contUDC(s) <br /> repairs for: Piping <br /> El fail safe Serial #: p g <br /> 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 /> O 1G - <br /> (L o �►" ct- 617 —ov 3 — 171,L-ED <br /> l��c r�•-� ��►-�rQ�+►r t,�-s (-,- <br /> i,5 Mejr. —A./ T ^,-- / <br /> THIS FACILITY IS SUBJE T TO REINSPECTI N AT ANI TIME AT EH 'S CURRENT HOURLY RATE. <br /> EHD Inspector. Re i d By: Title: ✓ <br /> -f J—,7 -e <br /> EHD 23-04 <br /> RPS nh/"/n7 <br />