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0 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.sisov.oreehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: U Service Request#: <br /> / 9 / o 00 6-41 <br /> Onsite Sen. Technician's Name: ICC Service Technician/Installer Certification#: Manufactu er Training- `` £ <br /> J� e '/'�t I�Ls��►✓1 F6 _ i�x �� U I ��/ Zell <br /> SERVICE SERVICE <br /> Leak detector <br /> ,19 V M L Spill bucket ❑ minimum 5 gallon <br /> mechanical Model: D?� ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: C X02 I �7/S ❑ 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 El minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro ammed ❑ Caldwell System ❑ Other <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor Secondary piping testing at: <br /> El ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> ❑ NA minutes <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% ED <br /> Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) Other: see below <br /> --kr <br /> SS y <br /> a lt:�nKm I za- &&1 40 ;;44p C. <br /> a THIS FACP.IJY IS SU ECT TO REINSPFc1rION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD tor: R ixkd By: Title: <br /> - v <br /> EHD 23-04 <br /> Rev 06/22/07 <br />