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SAN JOAUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 90 <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.ss3gov.or <br /> UNDERGROUND STORAGE TANK ST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Service T_ eehnicia�n/Installer Certification#: Manufacturer Training: <br /> X — I • 53 7Eak 2— 2� x'— I <br /> i <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ;itynechanical Model: EEl ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: -'? 1 1:7,4g ❑ Caldwell System ❑ Other <br /> 11 line test ro ammed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> -PEUnechanical Model: k ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: t2-7 1 ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> ❑ mechanical Model: F-1 ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test proEammed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> minutes <br /> ❑ NA <br /> sensor <br /> El positive shutdown Model: ❑ Secondary piping testing at: <br /> si <br /> [I 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 /> 10THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspect Rece' By: Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />