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SAN JOAQUIN COUNTY <br /> r-NVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web: www.siQov.ore/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: _ _ Inspection Date: <br /> SPP-a5 416 10r <br /> Facility Address: Service Request#: <br /> y-I0 MOW S . s o 156 6 `7 i <br /> Onsite Service Technician's Name: ICC Servfce Technician/Installer Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket 1:1 minimum 5 gallon <br /> El ❑ electronic Serial : ❑ El hour hydrostatic ❑ Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> F-1 ❑ electronic Serial 11 El hour hydrostatic ElIncon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial ElEl1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> Primary piping testing at: <br /> ❑ positive shutdown Model: <br /> F-1 <br /> El fail safe Serial #: El psi <br /> ❑ NA minutes <br /> sensor <br /> ❑ El positive shutdown Model: ElSecon psi piping testing at: <br /> ❑ fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial #: <br /> Sump(s) UST(s) <br /> El 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 /> THIS FACILITY IS SUBJECT TO REINSP§PMON AT Aly TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector / i e y: Title: <br /> 1144// <br /> EHD 23-04 <br /> Rev n0/9�m7 <br />