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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.si o�v.or_ /g ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Pate. <br /> Nj S Kf,fi Lp � 3 <br /> Facility Address: Service Request#: <br /> 3 �b S N S A0 El/ !fib 5 -7 � <br /> Onsite Service Technician's Name: ICC rvic Technicis Installer Certification#: Manufacturer Training: <br /> e 74/v L-10 <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket 1:1 minimum 5 gallon <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ <br /> El electronic Serial ❑ El hour hydrostatic El Incon TS-STS <br /> ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ electronic Serial ❑ [11 hour hydrostatic El Incon TS-STS <br /> ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> t• (� sensor f� - Primary piping testing at: <br /> El positive shutdown Model: ❑ psi <br /> El fail safe Serial #: y-j h- <br /> NA k minutes <br /> sensor , <br /> Secondary piping testing at: <br /> El positive shutdown Model: <br /> F-1 <br /> El fail safe Serial #: El psi <br /> minutes <br /> El 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 /> V of 1 sei Lnk <br /> �q v-' C ' C l IM -� <br /> rJ tS (� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIIVIE�ff EHD'S CURRENT HOURLY RATE. <br /> EHD Insor: R r e .d B Title: <br /> p / <br /> EHD 23-04 <br /> Rev 06/22/07 <br />