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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.sjgov.org%ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: (n� C Inspection Date: <br /> Facility Address: Service Request#: <br /> G(3,1 A vx- s fL vis 3,3 z3�3 <br /> Onsite Service Technician's Name: ICC Service Technician/installer Certification#: Manufacturer Training: V Z 13 <br /> 11 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial ElEl1 hour hydrostatic ElIncon TS-STS <br /> El Caldwell System ❑ Other <br /> El line test programmed <br /> Leak detector Spill bucket 1:1minimum 5 gallon <br /> El mechanical Model: ❑ El1 hour hydrostatic ❑ Incon TS-STS <br /> F-1 electronic Serial #: El Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> F-1 ❑ mechanical Model: 1:1 El hour hydrostatic El Incon TS-STS <br /> El electronic Serial #: El Caldwell System El Other <br /> El line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: p <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> E3 fail safe Serial #: <br /> minutes <br /> E] 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 /> S Khh I�r <br /> P/— L--,4-0 <br /> F 'T <br /> THIS FACILITY 19 SUBJECT TO REINSPETION AT ANY TIME AT EHD'e CURRENT HOURLY RATE. <br /> EHD Inspector: Rec i ed By: Title: J <br /> 15e-rU C-4t– <br /> EHD 23-04 <br /> Rev 06/22/07 <br />