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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sijzov.org/eh <br /> UNI)ERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility N I'� � Ins lion Date:O <br /> IE�� <br /> Facility Address: Serv'ce Re�stOE-7o <br /> Ons'a Service Techni ian's Name: V ICC Service Tech cian/Installer Certificati #: Manu acturer Training: <br /> ho I qV- uf /W- 1 01 <br /> SERVICE SERVICE <br /> Leak detector(E. Spill bucket ❑ minimum 5 gallon <br /> mechanical ',,Model: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial #: ❑ Caldwell System ❑ Other <br /> ❑ line test proy4nmed <br /> Leak detecto <br /> mechanical Model: L ��Q� Spill bucket ❑ minimum 5 gallon <br /> lC El F-1 electronic Serial #: ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed ❑ Caldwell System ❑ Other <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 /> ❑ <br /> El shutdown Model: El psi piping testing at: <br /> ❑ fail safe Serial #: p <br /> minutes <br /> 11 NA <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ 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 /> OR <br /> 5 .0 [° <br /> IS'FA I BJEC REINSPECTIO AT 6NY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD[n Received Title: <br /> EHD 23-04 <br /> Rav nR/99/n7 <br />