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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.or-g <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection te: <br /> Facility Address: Service Request#: <br /> - -72, -7 -2— W eS�- LN, , S v lC f�,,J S/, 00 S 16 S—© <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification 111 Manufacturer Training: <br /> Cie r u 2 ,� J ZbO� M:t ros <br /> SERVICE SERVICE <br /> Leak detector V," <br /> Spill bucket El minimum 5 gallon <br /> Kmechanical Model: q')— Lh 70" ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: 6-70 51 01 ❑ 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 programmed <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 /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Pi <br /> ❑ fail safe Serial #: ( ) pin g <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 below <br /> � ir-S f <br /> � s Z-1T C4 I; 6��4i�� <br /> C q1 '113 r e VS>!— Gyp, C VVI �-w o Qzl , of L) <br /> 1, proLa� reGe�� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRE T HOURLY RATE. <br /> EHD[ns ector: v I Received Title: <br /> /V �/ <br /> EHD 23-04 <br /> Rev 06/22/07 <br />