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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTME* <br /> 304 East Weber Avenue,3d Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date. <br /> 1,j <br /> .,( (q- 1 o-7 <br /> Facility Address: Service Request#: <br /> (23q %40,5S-^AtTI; HG-Nt,I-�' oe)sZ <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: <br /> 4-91— UT <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> F-1 mechanical Model: ")D <br /> 'electronic Serial#: El El 1 hour hydrostatic El Incon TS-STS <br /> programmed El Caldwell System 0 Other <br /> El line test <br /> Leak detector —Spill bucket El minimum 5 gallon <br /> ❑ D mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial #: 0 Caldwell System 0 Other <br /> El line test programmed <br /> Leak detector Spill bucket 0 minimum 5 gallon <br /> ❑ 0 mechanical Model: 0 El I hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System ❑ Other <br /> 0 line test proEammed <br /> sensor Primary piping testing at: <br /> D 0 positive shutdown Model: El psi <br /> El fail safe Serial#: minutes <br /> El NA I <br /> sensor Secondary piping testing at: <br /> 0 positive shutdown Model: 11 psi <br /> El fail safe Serial#: minutes <br /> DNA <br /> -sensor Secondary containment repairs for: <br /> El 0 positive shutdown Model: 0 UDC(s) Piping <br /> 0 fail safe Serial #: Sump(s) UST(s) <br /> DNA <br /> ❑ Drop tube with mechanical overfill at 95% 0 Cold start of monitoring panel <br /> n Drop tube with mechanical overfill at 95% 0 Corrosion protection <br /> 0 Overfill prevention(see LG letter 150-1) El Other: see below <br /> PL(-P <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EH 'S CURRENT HOURLY RATE. <br /> EHD Inspector: Receive y: <br /> EHD 23-04 <br /> 1/3/07 <br />