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SAN JOAQUIN COUNTY <br /> r ENVIRONMENTAL HEALTH DEPARTMENT <br /> a: 600 East Main Street,Stockton,CA 95202-3029 <br /> relephorte:(209)468-3420 Fax:(209)468-3433 Web:www,sigov.or elid <br /> UNDLRGROUND}STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> F Facility PCPW Iaepeti•n Date: ` <br /> Fact y rrew Service <br /> 41 <br /> Onsite Service Technician's Name: ICC Service Techaldn"tinstalier Certification N: Manufacturer Training: <br /> rTVIRVICE SERVICE <br /> Leak detector <br /> ❑ mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> #: <br /> ❑ line test ro mmed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> 11 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro ammed ❑ Caldwell System ❑ Other <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 Primary piping testing at: <br /> 0 Elpositive shutdown Model: <br /> ❑ fail safe Serial#: psi <br /> ❑ NA minutes I (!'6'sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> r <br /> ❑ ❑ fail safe Serial#: ❑ psi, ;,�� <br /> ❑ NA minutes ;G <br /> sensor <br /> ❑ 11 positive shutdown Model: ❑ Secondary contUD est repairs for: Pt <br /> ❑ fail safe Serial#: O ping <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 beig <br /> Re <br /> ,..� <br /> { <br /> f1 <br /> THIS IfCILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EfiD'lit t r <br /> A' <br /> eceived By Title: <br /> , 1 1410", � <br /> -- ." C d'1 _ icirl ', ':dill ✓►%., , . `+ <br /> EHO 23-04 { ' <br /> C)� CP��i- <br />