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■777 <br /> 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.sieov.org/ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION PORT <br /> Facility Name: Inspection Date: <br /> a I 7-;5.(OMFr(r 4') 90A) 0/12,5109 <br /> Facility Address: Service Request#: <br /> 1 S• � �Tb N -(7D Q SV- <br /> Onsite Service Technician's Name: ICC Service Technician/installer Certification#: Manufacturer Training: <br /> Y�! t u.c PfzF1'rr 1 G G o. 1�- A-zA- (o S — b <br /> SERVICE SERVICE <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 ❑ minimum 5 gallon <br /> ® ❑ electronic Serial#: ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El line test ro ammed ❑ Caldwell System ❑ Other <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> : <br /> ® <br /> F1 electronic Serial ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test ro ammed ❑ Caldwell System ❑ Other <br /> sensor <br /> ® ❑ positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑ fail safe Serial#: p <br /> ❑ NA minutes <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% Nr 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 /> s "' s V d ticg HUT <br /> X'- �� S is psc.TuieN mum OFF D w ®�i"h. 1 r &.shy a or <br /> N aT 1• -/WgjSjpE is RU N IU1 N No v,. - OLFgA21e <br /> N P 2ff t-tf '"b JeG- I <br /> TD '20 <br /> IW =Erja R 1- <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT NY TIME 4T EHD'S CURRENT HOtJRLY RATE.kVM N T <br /> EHD[nspector: a ( Receiv Title: p <br /> 2� <br /> EHD 23-04 <br /> Rev 06/22/07 <br />