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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DErARTME <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephoner(209)468-3420 Fax.(209)468-3433 Web:www.sihov.or ehd <br /> UNDERGROUND ST TANK UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: 1 F Inspection Date: <br /> �i 1 - <br /> Facility Address: Service Request#: <br /> ILI <br /> Onsite Service Technician's Name: IC ervice Technician/Installer Certification#: Manufa9turer raining: <br /> 1 am 01 &P ON LxD I <br /> SERVICE SERVICE <br /> Leak detector <br /> t Spill bucket El 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 Spill bucket ❑ minimum 5 gallon <br /> ❑ ❑ mechanical Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test pro ammed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ si <br /> ❑ fail safe Serial #: p <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ Psi. <br /> ❑ fail safe Serial #: p <br /> minutes <br /> El 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% ❑ Corrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> t nt 4- <br /> � t - <br /> f <br /> A 41 <br /> THIS F ILI IS JET T ( SPEC T ANYTIME AT EAd EH ' CURRENT HOURLY RATE. <br /> EHD Insp to Receiv By: . Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />