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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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: Inspect' n Date. <br /> M Ar- ( (Oo c. D ��� 1 2123/6`7 <br /> Facility Address: Service Request#: <br /> G �� S2VOC4 X3(6 <br /> Onsite Service Technician's Name: 1 C Service Technician/Installer Certification#: Manufacturer Training: <br /> C� --UT �- <br /> ti� ut z oG <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: y���Ud `0115 E] El hour hydrostatic ❑ Incon TS-STS <br /> electronic Serial #: 7�Z LJ�e El System ❑ Other <br /> El line test ro rammed <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 /> sensor <br /> ❑ El shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> ❑ NA minutes <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 /> '1 1 yl2 Qi <br /> Oo l- L L -ems <br /> v �?Lxs i jtll kw <br /> THIS FACILITY IS SUBJECT T REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EH spector: Received By: Title: <br /> EHD 23-04 <br /> 1/3/07 <br />