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SAN JOAQUIN COUNT:' <br /> - :NYiRONvfiN� �L �EALr! DEPARTMENT <br /> 600 East Mahn Street,Stockton,CA 95202-3029 <br /> {_ Telephone:(209)46$-3420 Fi x.(209)468-3433 Web:WWW.SjgQV.0TgZehd ' <br /> f UNDERGROUND STORAGE TANK S PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> E Facility Name: onspvrtion Date: <br /> (A <br /> Facility <br /> Facility Address: Service Request#: <br /> 15D�t'aN5 �prD &9,00 5'�F- % . <br /> Onsite Service Technician's Name: ICC Service TuhniciatiVinstaller Certiracation 11: manufacturer Training <br /> `til GI td 5T 0 R SZS'V 052 +iI I 2411(o ko,5 t - T trAA-k-" % <br /> M+4 <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ 11 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: <br /> El line test ro amrned ❑ Caldwell System El Other ; <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ Cl I 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 r <br /> sensor <br /> M <br /> El El positive shutdown Model: Primary, ppsi -5 testing1 dw at Vit VA <br /> ❑ fail safe Serial#: �minutes W <br /> ❑ NA <br /> sensor <br /> Second piping testing at: <br /> El positiveshutdown Model: ❑ p <br /> si <br /> ❑ fail safe Serial #: minutes <br /> ❑ 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 /> 1!�=imir W""I <br /> �> <br /> PST <br /> Af <br /> Wvs8121 <br /> w-z► o C.1 <br /> THIS FACILITY IS SUBJECT TO REIN PECTION AT ANY TIME AT END'S CURRENT HOURLY RATE. <br /> HH[)Inspect gF: y � Rec ived By: Title: <br /> EHD 23-04 <br /> aPu nsi2:2107 <br />