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SAN JOAQUIN COUNTY 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue, 3rd Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Pax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> vmo ©lam CJS 1-v5Lt`t� 17--(O`v-7 <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service ren/Installer Certification#: Manufacture Training: p <br /> �cj rLD'1 C V v <br /> SERVICE SERVICE <br /> Leak detector 5L_ Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: R 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 /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System El Other <br /> sensor <br /> El El positive shutdown Model: ElPrimary piping testing at: <br /> si <br /> 13 fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor <br /> F-1 El shutdown Model: El psi piping testing at: <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Pi <br /> El fail safe Serial #: ( ) pin g <br /> El NA sump(s) UST(s) <br /> V'5t-� 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 /> V:�,V-7-4 s� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> EHD 23-04 <br /> 1/3/07 <br />