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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.sj_gov.or2/ehd <br /> UNDERGROUND STORAGE TANK(UST) PROGRAM SERVICE REQUEST INSPECTION REPORT <br /> Facility Name: Inspec'on Date, <br /> UPS 1 I --1 7 ve <br /> Facility Address: Servick Request#: <br /> Onsite Service Technician's Name: ICC Service Technicia Installer Certification#: Manufacturer Training: <br /> M i Q Z 2 0e 1 I l�Cb°l . Omvt) <br /> b <br /> SERVICE SERVICE <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 /> 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 Primary piping testing at: <br /> ❑ ❑ positive shutdown Model: ❑ psi <br /> ❑ fail safe Serial #: <br /> ❑ NA minutes <br /> sensor Secondary piping testing at: <br /> ❑ positive shutdown Model: <br /> E] ❑ fail safe Serial #: � S psi <br /> El NA 60 <br /> minutes <br /> sensor Secondary containment repairs for: <br /> ❑ ❑ positive shutdown Model: ^ UDC(s) gr4vo 4ttx D1skiping <br /> 11 fail safe Serial#: J� <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% XCorrosion protection <br /> ❑ Overfill prevention(see LG letter 150-1) ❑ Other: see below <br /> on C 41'e-, <br /> �-THIS FACILITY IS SUBJECT TO REINSP IO AT MY T S CURRENT HOURLY RATE. <br /> EHDec r: eiv By: Title• <br /> WPC-1/1 I )4 4641� IkA #A <br /> EHD 23-04 1 ( 6"�YUyVFP",/ 10 1 V,/ <br /> Rev 06/22/07 <br />