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r 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.s1gov_or ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date- <br /> *to Ad"O ✓1 7,Iz010 ,� <br /> Facility Address: Service Request#: <br /> 1"71 1 0,,-c- 6l ,+f,, Sfz.O a S$ <br /> -� d <br /> Onsite Service Technician's Name: WC Service Tech nician/1nstaller Certification#: Manufacturer Training: <br /> Z 52,6 ?15 —u'F /0 /ill b 6 6?,Z-(4- tlI/[a <br /> SERVICE SERVICE <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 /> Leak detector <br /> F-1 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial El El hour hydrostatic ❑ Incon TS-STS <br /> El Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ Elpositive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> 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% ❑ tOoth�er- see <br /> Cn protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ below <br /> 9ne � -%LS 3sD k , <br /> n/&,) w,Z LD zat) <br /> of da 3 <br /> r <br /> FACI ITY IS BJ T T RE SP CT ON AN T E AT E 'S CURR NT OU LY RATE. <br /> D Inspector: YV r I-Irec'eivedfy: it e: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />