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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d 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 /> "me(Z- 7-to-0-7 <br /> Facility Address: Service Request#: <br /> 3�fl y w• �I Aw�,+►nrv2 t� • S Ro-o�-a2�5 <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Training: 6� <br /> Nkcx Pt,/,pR.�S SZ�g39V —LA t 4a_t2-o1 (bf� 4 14A � <br /> SERVICE SERVICE <br /> Leak detector Spill bucket X minimum 5 gallon <br /> ❑ mechanical Model: <br /> ❑ <br /> El electronic Serial#: 1 hour hydrostatic El Incon TS-STS <br /> ❑ line test programmed <br /> El 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 /> 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 /> ❑ ❑ positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> ❑ fail safe Serial#: p <br /> El minutes <br /> sensor Secondary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: minutes <br /> ❑ NA <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ❑ UDC(s) Piping <br /> ❑ fail safe Serial#: ( ) p <br /> ❑ NA Sump(s) UST(s) <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 /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspector: Received By: Title: <br /> 1 L(- 06% <br /> EHD 23-04 <br /> 1/3/07 <br />