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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgoy.orRjehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> 6�1' 11,6 <br /> Facility Ad ss: Service Request#: <br /> w : I a6i� i�/ i <br /> OnO7 Service T hni Ian's Name: MC Service Technician/Installer Ce i6cation#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector <br /> E] mechanical Model: Spill bucket El minimum 5 gallon <br /> ❑ <br /> El electronic Serial ❑ El hour hydrostatic El Incon TS-STS <br /> ❑ Caldwell System 11 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 /> 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: ❑ Primary piping testing at: <br /> si <br /> El fail safe Serial #: p <br /> minutes <br /> ❑ NA <br /> sensor <br /> Secondary <br /> ❑ positive shutdown Model: ❑ si piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor <br /> ❑ ositive shutdown Model: Se onda containment repairs for: <br /> ❑ <br /> El fail safe Serial #: �J1b t � � UDC(s) Piping <br /> ❑ NA Sump(s) UST(s) <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 /> d- U V, 7 JV5b - <br /> 1 WL41al5 ikd- <br /> uyry k6 vel o 1 -i <br /> _N a VOW t�euW is �U�,, l ke <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> E D Inscolt I Recei By: Titae <br /> L*4 V <br /> / L <br /> EHD 23-04 <br /> Rev 06/22/07 <br />