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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.sigov.or <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> V'e0Pv /6 Loq <br /> Facility Address: Service Request#: <br /> /.234- 'loss-m l 72F 14V47WA)Z7E1_-A sf-6-6 5Za 3 S <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> — UT jj iblocjB S2 S3 �1Zsl� <br /> SERVICE SERVICE <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> 21 El ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> JO electronic Serial#: ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket ❑ minimum 5 gallon <br /> 11 ❑ electronic Serial : El El hour hydrostatic ❑ Incon TS-STS <br /> ❑ line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket ❑ minimum 5 gallon <br /> El ❑ electronic Serial El 1 hour hydrostatic ❑ Incon TS-STS <br /> El Caldwell System ❑ Other <br /> ❑ line test programmed <br /> sensor <br /> ❑ <br /> El shutdown Model: 11 psi piping testing at: <br /> ❑ fail safe Serial#: p <br /> minutes <br /> ❑ NA <br /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Secondary piping testing at: <br /> 11 fail safe Serial#: p <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 /> -r"4 6n,,2 <br /> E44 <br /> Li.✓ <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANYTWE E AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Rece' By: Title: <br /> EHD 23-04 <br /> Rav ns/99/n7 <br />