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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.sjgov.or /g ehd <br /> UNDERGROUND STORAGE TANK UST PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspection Date: <br /> Z /?o0 <br /> Facility Address: Service Request#: <br /> Onsite Service Technician's Name: ICC Serves Technician/installer Certification#: I Manufacture Train► j�s <br /> 1.r:t, Al 2S D 2 0 0-UT VI-T h6u V M 1 � �!off' � � sr'Jl oq <br /> SERVICE SERVICE <br /> D est Leak detector <br /> f,�.mechanical Model:�Cj-�_(� �CCJ(� Spill bucket El minimum 5 gallon <br /> ❑ ❑ 1 hour hydrostatic ❑ Incon TS-STS <br /> ❑ electronic Serial#: 09 ❑ Caldwell System ❑ Other <br /> ❑ line test programmed <br /> Leak detector <br /> ❑ mechanical ModelSpill bucket El minimum 5 gallon <br /> : <br /> ❑ ❑ electronic Serial ❑ ❑ 1 hour hydrostatic El Incon TS-STS <br /> El line test programmed <br /> El Caldwell System ❑ Other <br /> Leak detector <br /> El mechanical Model: Spill bucket El minimum 5 gallon <br /> El ❑ electronic Serial ❑ El hour hydrostatic ElIncon TS-STS <br /> ❑ ro ammed ❑ Caldwell System 11 Other <br /> line test <br /> sensor <br /> ❑ ❑ positive shutdown Model: ❑ Primary piping testing at: <br /> si <br /> El fail safe Serial#: p <br /> minutes <br /> ❑ NA <br /> sensor <br /> Second <br /> 11 1:1 positive shutdown Model: 1:1Sry piping testing at: <br /> E] fail safe Serial#: p <br /> minutes <br /> El NA <br /> sensor <br /> El positive shutdown Model: Secondary containment repairs for: <br /> El ❑ fail safe Serial#: ❑ UDC(s) Piping <br /> El 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 /> G -- 0-1 N&J t-! /-- <br /> A /I11r <br /> girlPAAM Adj ' <br /> 2.s/Zoo4 <br /> • mss k <br /> THIS FACILITY IS SUBJECT TO REINSPECTION AT Alf'UK AT EHD'S CURRENT HOURLY RATE. <br /> EHD Inspec . tReceived By Title: <br /> EHD 23-04 <br /> Rev 06/22/07 <br />