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0 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.sigoy.org/ehd <br /> UNDERGROUND STORAGE TANK(UST I PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Nqqrne: Inspection Date: <br /> e-n <br /> 1141'/,ol-r- -17 7,11 V q <br /> Facility Address: Service Requesf#: <br /> 1 4 <br /> (gc)56/ <br /> Onsite Service Technician's Name: ICC Service Technician/I!!sta Certification#: Manufacturer Training: <br /> SERVICE SERVICE <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El 0 mechanical Model: ❑ 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: El Caldwell System ❑0 Other <br /> 0 line test 2roEammed <br /> Leak detector Spill bucket El minimum 5 gallon <br /> El 0 mechanical Model: El 0 1 hour hydrostatic 0 Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System F1 Other <br /> 0 line test programmed <br /> I Leak detector Spill bucket 0 minimum 5 gallon <br /> ❑ 0 mechanical Model: 0 0 1 hour hydrostatic El Incon TS-STS <br /> 0 electronic Serial#: 0 Caldwell System 0 Other <br /> 0 line test 2roEammed <br /> sensor❑ Primary piping testing at: <br /> 0 positive shutdown Model: 0 psi <br /> 0 fail safe Serial#: minutes <br /> 0 NA <br /> sensor Secondary piping testing at: <br /> ❑ 0 positive shutdown Model: 0 -psi <br /> 11 fail safe Serial#: minutes <br /> DNA <br /> sensor Secondary containment repairs for: <br /> ❑ 0 positive shutdown Model: 0 UDC(s) Piping <br /> 0 fail safe Serial#: sump(s) UST(s) <br /> 0 NA I <br /> D Drop tube with mechanical overfill at 95% 0 Cold start of monitoring panel <br /> Drop tube with mechanical overfill at 95% 11 Corrosion protection <br /> Overfill prevention(see LG letter 150-1) Other: see below <br /> ------ <br /> jr <br /> P'r- 6P <br /> 00!±-(=n cafl <br /> THIS FACILITY IS SUBJECT TO REINSPECTION TIMy EHDIS CURRENT HOURLY RATE. <br /> A A <br /> EHD Inspect oe— Received By: <br /> By: Title: <br /> VI-ill <br /> EHD 23-04 <br /> Rev 06/22/07 <br />