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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT '6b <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sj%4ov.orjz/eh <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection ate: <br /> A. -f Z CLQ P/`l�' -�soda Z v <br /> Facility Address: Service quest#: <br /> Zprt/t, !'/ZPC:) S3 g�3 Z <br /> Onsite Service Technician's Name: ICCtervice echnician/inst er C ification#: Manufacturer Training: <br /> Ac( <br /> d SERVICE SERVICE <br /> ` Leak detector <br /> ❑ mechanical Model: L-�� Spill bucket El minimum 5 gallon <br /> �electronic Serial #: �L�(�� � ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> tidMeak detector <br /> �, Spill bucket ❑ minimum 5 gallon <br /> F-1 mechanical Model: P Lk� E] ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> El electronic Serial#: F-1 Caldwell System 11 Other <br /> ❑ line test programmed <br /> Leak detector <br /> mechanical Model: p�- L-)J Spill bucket El minimum 5 gallon <br /> ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> `electronic Serial#:2 70 6'610-- ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> 11 fail safe Serial#: <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 /> ih Fi �D �r1 v N G 7 D c7 &J S _ �• J <br /> I1 l] «, <br /> C Llls� Ln DL <br /> 246 -6Y!�� <br /> THIS FACILITY IS SUBJ CT TO REINS ON AT Y TIME AT EHD'S CURRENT ROURLY RATE. <br /> EHD In tor: Rec ived Title: <br /> C <br /> PEHD 23-04 <br /> Rev 06/22/07 <br />