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t # SAN JOAQUIN COUNTY 16 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fara.(209)468-3433 Web:www.sigov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> C lteyf2_6"' 3110109 <br /> Facility Address: Service Request#: <br /> t103 s MAIN &747C-T.1. r0 / 5,-o o q o t 9 <br /> Onsite Service Technician's Name: ICC Service Technicianlinstaller Certification#: Manufacturer Training: <br /> 5L595%0 - ui Nor ak,,, `' <br /> SERVICE SERVICE <br /> Leak detector <br /> 1-1 mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> ❑ <br /> 11 electronic Serial #: ❑ El hour hydrostatic El Incon TS-STS <br /> El Caldwell System ❑ Other <br /> El 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 Model: Spill bucket El minimum 5 gallon <br /> ❑ ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: <br /> ❑ Caldwell System ❑ Other <br /> El line test programmed <br /> y <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial#: <br /> minutes <br /> 11 NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: psi <br /> El Elfail 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 #: ( ) p g <br /> ❑ NA Sump(s) UST(s) <br /> �Z Drop tube with mechanical overfill at 95% ❑ Cold start of monitoring panel <br /> f _Drop tube with mechanical overfill at 95% ❑ Corrosion protection <br /> ❑ Overfill prevention (see LG letter 150-1) ❑ Other: see below <br /> C, <br /> THIS FACILITY IS SUBJ CT TO REINSPECTION &ANY TIME AT EHD'S &IRRENT HOURLY hATEY <br /> EHD Inspector:, _ Receiv y: Title: <br /> M <br /> EHD 23-04 <br /> Rev 06/22/07 <br />