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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEO <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sis;ov.or ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: In ection Date: <br /> 1—f 0 <br /> Facility Add ss:-1539+n � � `vice Request#: <br /> N . ►�''LJ vgb (��M I <br /> o <br /> Onsite Service Teccian's me: ICC Service Technician/Installer Certification#: Manufacture Training: <br /> )� <br /> i � Y <br /> SERVICE SERVICE <br /> Leak detector Spill bucket inimum 5 gallon <br /> mechanical Model: j ;Z 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: � ` El Caldwell System ❑ Other <br /> El line test programmed <br /> Leak detector ��pill bucket minimum 5 gallon <br /> ElElmechanical Model: 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial #: El 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 <br /> El El positive shutdown Model: ElPrimary piping testing at: <br /> si <br /> El fail safe Serial #: p <br /> minutes <br /> El NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> minutes <br /> ❑ 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 /> f <br /> f <br /> T IS,f#CILWY I SUBJE T TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> D s o : Rece' By: . Title: <br /> D 23-04 <br /> Rev 06/22/07 <br />