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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENI <br /> 304 East Weber Avenue, 3'd Floor, Stockton,CA 95202-2708 <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: Inspection Date. <br /> 3 " H - () <br /> Facility AddresV Service Request#: <br /> (SO q 3 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> u-r t-6 Z -I- <br /> SERVICE SERVICE <br /> Leak detector <br /> Spill bucket El minimum 5 gallon <br /> F-1 Li mechanical Model: LIUAR feo# ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> EA electronic Serial #: ZN C� ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial El El hour hydrostatic ElIncon TS-STS <br /> El line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ El El❑ electronic Serial #: 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed 1:1 Caldwell System ❑ Other <br /> sensor <br /> El El shutdown Model: ❑ Primary piping testing at: <br /> si <br /> El fall safe Serial #: p <br /> minutes <br /> El NA <br /> sensor <br /> El El positive shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor <br /> ❑ El positive shutdown Model: El Secondary containment repairs for: Piping <br /> El fail safe Serial #: ( ) p g <br /> p <br /> El NA Sump(s) UST(s) <br /> El El <br /> tube with mechanical overfill at 95% El Cold start of monitoring panel <br /> F-1Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ro Other: see below <br /> L <br /> itj <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> ENXpector: e y: / Titl(14e <br /> / y <br /> EHD 23-04 <br /> 1/3/07 <br />