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?4 <br /> 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.sgov.org'ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> U 2 CN, _?/ /goo <br /> Facility Address: Service Request#: <br /> 2 roc dmay 5 'D /� <br /> Onsite Service Technician's Name: ICC Service Technician/Installer Certification#: Manufacturer Trainin <br /> r:C Int '2.5U C 0U-UT V13holl VM 1 ��, z10 4-/4 coq <br /> SERVICE SERVICE <br /> Leak detector Spill bucket ❑ minimum 5 gallon <br /> is Kelectronic <br /> mechanical Model: -TCEl131 hour hydrostatic ❑ Incon TS-STS <br /> Serial #: OR , C ❑ 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 /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial ElEl1 hour hydrostatic ElIncon TS-STS <br /> ❑ Caldwell System El Other <br /> ❑ line test programmed <br /> sensor Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> El fail safe Serial #: <br /> minutes <br /> ❑ NA <br /> sensor <br /> ❑ positive shutdown Model: Secondary piping testing at: <br /> ❑ 1:1fail safe Serial#: ❑ psi <br /> minutes <br /> El NA <br /> sensor Secondary containment repairs for: <br /> El 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 /> � c1' e l- <br /> UY1 ' r'n <br /> a� <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT ANY TIME AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspecto: Received Bye% Title: <br /> r <br /> EHD 23-04 <br /> Rev 06/22/07 <br />