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SAN 7fOAQUI1`!COUNTY <br /> ItVIRONMEfi_fAi.HEAi,iv DEPAiCl MEAT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sig-ov.or 1g ehd <br /> UNDERGROUND STORAGE TANK ST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Faciii Name: Inspection Date: <br /> f-n ?ZT" .1(0 .0 Cl <br /> Facility Addres : Service Request#: <br /> 3 2� 0 , `F11m ► *005�,3 3'�;_ <br /> Onsite Service Technician's Name: J ICC ServiceTechnician/Installer Certificate n#: Manufacturer Training: <br /> *y <br /> � iC "0-O x-322 to 3 -3- IT s/ Ann- b3�-93 <br /> SERVICE SERVICE <br /> Leak detector _Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ ❑ electronic Serial #: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> F-1linetest programmed <br /> ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> ❑ <br /> El electronic Serial : El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑ fail safe Serial #: p <br /> — minutes <br /> ❑ NA <br /> sensor <br /> El positive shutdown Model: _ ❑ Secondary piping testing at: <br /> [I fail safe Serial #: - p <br /> minutes <br /> 01 NA <br /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Secondary containment repairs for: <br /> DPi <br /> El fail safe Serial #: ( ) Piping <br /> 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 /> 77 (�71 AVAF� <br /> THIS FA ILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> ti pest Received By: Tide: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />